CQC report explained · a nursing home
What the CQC found at St. Ives Country House Care
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people were protected from abuse and avoidable harm. Staffing, recruitment, medicines, infection control, premises safety and learning from incidents were all checked and found to be managed safely.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its rating was carried over from the previous inspection when calculating the overall rating.
- Well-led?
- Good
- Inspectors found a very positive and open culture, strong management oversight, regular audits and active involvement of people, relatives and staff.
What inspectors found, November 2023
Rated Good; inspectors found safe care and strong leadership, with some concerns about agency staff and staffing levels.
This was an unannounced focused inspection on 19 October 2023. Inspectors reviewed information held about the home, spoke with people, a relative, staff and managers, and contacted relatives by telephone. They also checked care records, medicines records, staff recruitment files, audits and premises safety records.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found people were protected from abuse, medicines were managed safely, the premises were clean and well maintained, and risks were managed without unnecessarily restricting people's lives.
Inspectors found an open management culture, good oversight and clear plans for improvement. The overall rating also used ratings from the previous inspection for the other three questions, because this inspection did not examine Effective, Caring or Responsive.
Safeguarding and risk management
Staff understood safeguarding and whistleblowing. Risks were assessed and managed while people were encouraged to make choices and take part in activities and outings.
“People were encouraged to take positive risks and a wide range of activities and outings enabled people to lead fulfilling lives.” from the report
Medicines
Medicines were securely stored, checked and recorded. Staff were trained and assessed before giving medicines.
“The electronic system meant there were few medicines errors and omissions, or late medicines were flagged to ensure they were given.” from the report
Clean and safe premises
The home was very clean and maintained. Infection prevention measures, including suitable protective equipment, were in place.
“The premises were very well maintained and extremely clean and all necessary infection prevention and control measures were in place.” from the report
Open management
People, relatives and staff could speak with managers easily. Audits and an improvement plan gave managers regular oversight of the service.
“The management team had an open-door policy and staff, people and relatives frequently accessed them.” from the report
Person-centred care
Care records included detailed personal histories and support needs. The report says staff used this information to engage with people living with dementia.
“There was an electronic care record that was completed to a very high standard without exception.” from the report
Agency staff and continuity
minorOne relative said agency staff were not always as good as permanent staff and that familiar faces were important. Other relatives said care was not adversely affected, so this was mixed feedback rather than a reported breach.
“Staff are wonderful, but there are agency staff who are not as good as permanent staff.” from the report
Staffing levels
minorRelatives gave mixed views about staffing numbers. Some reported occasional periods when there were not enough staff, although they said this had not affected the care provided.
“The last few months there was a little time when they didn't [deploy enough staff].” from the report
- 01How many agency staff are currently being used, and how do you make sure they know each person's care needs?
- 02How do you maintain familiar carers and continuity for people who need regular faces?
- 03How do you check staffing levels each day when people's needs change or there is a new admission?
- 04What activities and outings are available for people, including people living with dementia?
- 05How can relatives raise concerns directly with the management team and hear what action was taken?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 11 November 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
St. Ives Country House Care was inspected but not rated; inspectors found good infection control and visiting arrangements.
This was an announced, targeted inspection on 3 February 2022. It focused on infection prevention and control, visiting arrangements and the effect of COVID-19 staffing pressures.
Inspectors found that the home had measures to manage infection risks. These included visitor testing, temperature checks, PPE, hand hygiene, vaccination checks and staff testing. They were assured that the home was using PPE safely, keeping the premises clean and managing possible outbreaks.
People told inspectors they felt happy and safe. The home supported contact with relatives as restrictions changed and used risk assessments for care, visitors and trips out.
The service was inspected but not rated. Only the Safe question was inspected, so this report does not provide ratings for Effective, Caring, Responsive or Well-led.
Infection control
Inspectors found robust policies, regular checks and good practice to help keep people safe from infection.
“Robust policies and procedures together with regular audits and checks meant that the home worked in line with good practice and government guidance.” from the report
PPE and cleanliness
PPE supplies were good, staff used PPE correctly and the home was clean, including frequently touched areas.
“Supplies of PPE were in good supply, stock checks maintained, and we observed staff wearing this correctly.” from the report
Contact with relatives
The home adapted its visiting arrangements as restrictions changed and kept people and relatives informed.
“People were supported to maintain vital contact with their loved ones during the COVID-19 pandemic.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your infection prevention and control arrangements changed since the February 2022 inspection?
- 02What are the current arrangements for visiting, including testing, PPE and hand hygiene?
- 03How would you manage an infection outbreak, and how would residents keep in contact with relatives?
- 04What measures are in place now to manage staffing pressures during illness or COVID-19?
- 05Can you show us how risk assessments are completed for visitors and residents going out of the home?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; only Safe was inspected and it was not rated. This explanation was written from the published report of 15 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St. Ives Country House Care
2 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- April 2018GoodSafe: GoodWell-led: Good
- January 2017
Registered with the Care Quality Commission on 27 January 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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