CQC report explained · a residential care home
What the CQC found at St James Mews
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines, safeguarding, fire safety and infection control had improved. However, bowel charts were not always completed, and guidance for diabetes, constipation and refused care was not always detailed enough.
- Effective?
- Requires improvement
- Care plans, communication support, staff training and consent processes had improved. Further work was needed on guidance for one person's safety when leaving the home and on medicines competency checks.
- Caring?
- Requires improvement
- This question was not assessed during this focused inspection. The report says people received kind and compassionate care and that staff protected people's privacy and dignity.
- Responsive?
- Requires improvement
- This question was not assessed during this focused inspection. The report describes person-centred care plans, support for communication and help with people's interests, goals and aspirations.
- Well-led?
- Requires improvement
- Management systems and the culture had improved, but daily notes, cleaning schedules and some other records were not always completed or kept up to date. There was no registered manager in post at the time of inspection.
What inspectors found, January 2023
Rated Requires Improvement; inspectors found major progress since the last inspection, but some risks and records were still not managed consistently.
Inspectors made an unannounced, focused inspection visit on 5 December 2022. They looked at Safe, Effective and Well-led. They spoke with people, a relative and staff, observed care, and checked care, medicines, staff and management records.
The home had improved from an Inadequate rating at the previous inspection. Inspectors found better medicines management, safeguarding, staff training, care planning, infection control and the home environment. People were supported with kindness, dignity, communication and personal goals.
Some important improvements were still needed. Records about bowel movements, daily care, cleaning and health needs were not always complete. There was also not always enough guidance about diabetes, constipation, refusing care and one person's safety when leaving the home independently.
The home was no longer in breach of regulations and was no longer in Special Measures. However, Requires Improvement means inspectors found the service was not consistently safe, effective or well-led. The Caring and Responsive questions were not assessed during this focused inspection.
Safer medicines
Inspectors found that medicines were being administered, stored and recorded more safely. Guidance was in place for as-required medicines, and epilepsy rescue medicines were available.
“People were supported by staff who followed systems and processes to administer, store and record medicines safely.” from the report
Kind and respectful care
People received compassionate care. Staff understood individual communication needs and supported privacy, dignity and choice.
“However, people received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Support for goals
Staff helped people pursue interests and work towards personal goals. Key worker reviews recorded aspirations and followed up actions.
“Staff supported people to achieve their aspirations and goals, for example, monthly key worker reviews detailed what aspirations people had and then this was reflected in the following review as a completed action.” from the report
Improved safeguarding
Staff knew how to recognise and report abuse. Relevant incidents were referred through the correct processes, and relatives said their loved ones felt safe.
“People were kept safe from harm because staff knew them well and understood how to protect them from abuse.” from the report
Improved environment
The home had been repaired and redecorated. Inspectors found it clean and homely, with a safe area for people to prepare and cook food.
“The provider had improved the environment by making repairs where they were needed and redecorated communal areas.” from the report
Incomplete bowel records
seriousBowel charts were not consistently completed for someone at risk of constipation. This meant inspectors could not be sure that as-required medicines would be given at the right time.
“The person's bowel chart was not consistently completed, and we could not be assured they would receive their medicines when required.” from the report
Gaps in health guidance
needs fixingThere was not always enough guidance for staff about diabetes and constipation risks. Guidance was also not always detailed enough when someone refused care.
“There was not always guidance in place for staff to follow when supporting people who lived with diabetes.” from the report
Incomplete records
needs fixingDaily notes, cleaning schedules and records of health needs were not always completed or detailed consistently. The home manager knew this needed improvement.
“Record keeping for daily activities, health needs and cleaning were not always up to date or being completed by staff.” from the report
No registered manager
needs fixingThere was no registered manager in post when inspectors visited. The home manager planned to apply to become the registered manager.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How are you now checking that bowel charts and other health records are completed accurately every day?
- 02What guidance is now in place for diabetes, constipation, refused medicines and a person's safety when leaving the home independently?
- 03Is there now a registered manager, and if not, when will the application be submitted?
- 04How often are staffing gaps covered by agency staff, and how do you maintain continuity for residents?
- 05What actions remain on the improvement plan, and how will you show that daily notes and cleaning records are complete?
This was a focused inspection of Safe, Effective and Well-led only; the Caring and Responsive questions were not inspected and the overall rating used the previous ratings for those areas. This explanation was written from the published report of 31 January 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, October 2022
St James Mews was rated Inadequate and placed in special measures; inspectors found serious risks in care, medicines, staffing and management.
This was an unannounced inspection over three visits in May 2022. Inspectors spoke with people living at the home, relatives and staff. They observed care and checked care plans, medicines records, staff files and management records.
Inspectors found serious gaps in risk assessments and guidance for epilepsy, choking, diabetes and constipation. Medicines were not always given or stored safely. Some staff lacked up-to-date training, including training needed for specific health conditions and communication methods.
The home did not always protect people from abuse or respect their choices. Inspectors also found damaged flooring, a poorly maintained electrical box, incomplete care records and weak checks by managers. There were some positive activities and respectful interactions, but these did not outweigh the risks.
The overall rating was Inadequate. Safe, Effective and Well-led were rated Inadequate. Caring and Responsive were rated Requires Improvement. The previous overall rating was Good, published in January 2019. The home was placed in special measures and the provider was required to make improvements.
Personalised rooms
People could personalise their rooms and were involved in decisions about decoration.
“People personalised their rooms and were included in decisions relating to the interior decoration.” from the report
Individual activities
Staff supported people with activities linked to their interests, including horse riding, gym visits and using a trampoline.
“People were able to take part in activities and pursue interests that were tailored to them.” from the report
Positive interactions
Inspectors observed some respectful support and encouragement for people to be independent.
“We also observed positive and respectful interactions between staff and people.” from the report
Recruitment checks
The provider completed pre-employment checks before staff started work, including criminal records checks.
“Safe recruitment processes were followed.” from the report
Health risks were not managed
seriousThere were no suitable care plans or guidance for some people's epilepsy, choking, diabetes or constipation risks. One person's constipation medicine had been stopped by staff without medical advice.
“People were not always kept safe from the risk of harm.” from the report
Medicines were not always safe
seriousStaff were crushing a slow-release epilepsy medicine, and guidance for some as-required medicines was missing. Medicine storage checks were also not reliable.
“People were supported by staff who did not always follow systems and processes to administer and record medicines safely.” from the report
Staff training was inadequate
seriousMany training courses had expired. Less than half of staff had current training in diabetes, dysphagia and emergency epilepsy medicine administration, and agency staff records were missing.
“The number and skills of staff did not match the need of people using the service.” from the report
Safeguarding concerns
seriousSome safeguarding information was not reported accurately, and a complaint that someone felt unsafe was not reported as a safeguarding alert.
“People were not always kept safe from avoidable harm because staff were not always able to protect people from abuse.” from the report
Care and communication records
seriousCare plans were incomplete, conflicting or overdue for review. The home did not always provide visual communication aids or current Makaton support.
“The provider failed to ensure peoples individual communication needs had been supported.” from the report
Weak management oversight
seriousManagement systems failed to identify or correct repeated problems. Some required welfare checks were not recorded, and important incidents were not always notified to CQC.
“The providers system for governance had not been effective in identifying the issues we found during this inspection.” from the report
- 01What has been done to put clear, person-specific plans in place for epilepsy, choking, diabetes and constipation?
- 02How do you now check that all permanent and agency staff have current training and are competent to support each person?
- 03What changes have been made to medicine administration, including slow-release medicines and as-required medicines?
- 04How are safeguarding concerns, complaints and incidents now recorded, reported and followed up?
- 05What evidence can you show that care plans, welfare checks, activities and management audits are now complete and up to date?
This was an unannounced inspection covering all five key questions, prompted in part by concerns about staffing, medicines and infection prevention and control. This explanation was written from the published report of 19 October 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 James Mews
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2022Inadequatedown from GoodSafe: InadequateEffective: InadequateWell-led: Inadequate
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015
Registered with the Care Quality Commission on 6 March 2015.
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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