CQC report explained · a nursing home
What the CQC found at St Johns Nursing Home Limited
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 were administered appropriately, but medicines administration records were not always completed. Earlier gaps were also found in turning, hydration and weight records, although new audits had addressed these shortfalls.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff were trained and supervised, and people received suitable support with eating, drinking, healthcare and their legal rights.
- Caring?
- Good
- Staff treated people with kindness, privacy and dignity. People were involved in decisions about their care and supported to maintain their independence and relationships.
- Responsive?
- Good
- Care was personalised to people's needs, choices and communication needs. People had access to activities, visitors, complaints processes and specialist end of life support when needed.
- Well-led?
- Requires improvement
- A new manager had introduced audits, an improvement plan and changes to staffing. However, the improvements were recent and had not yet been shown to be sustained, and there was no registered manager in post.
What inspectors found, February 2023
St Johns Nursing Home Limited was rated Requires Improvement; inspectors found kind and effective care, but medicines records and management checks were not yet reliable.
This was an unannounced inspection on 10 January 2023. Inspectors spoke with people, staff, nurses, the new manager and healthcare professionals. They checked care records, medicines, staff files and quality checks.
People were generally treated kindly and with dignity. Their care was personalised, their choices were respected, and they received support with food, drink, healthcare, activities and relationships. Staff had the training and skills needed to provide care.
The main safety problem was incomplete recording. Medicines administration records had gaps. There were also earlier gaps in turning, hydration and weight records. A new manager had started audits and other improvements, but the inspectors wanted to see these changes continue and become reliable.
The overall rating was Requires Improvement. Safe and Well-led were rated Requires Improvement, while Effective, Caring and Responsive were rated Good. The home remained in breach of Regulation 12 about safe care and treatment.
Kind and respectful care
People described staff positively and inspectors observed warm interactions. Staff supported privacy, dignity, choice and independence.
“We observed staff and people sharing warm interactions throughout the day and staff we spoke with described people respectfully.” from the report
Trained staff and staffing levels
The home had recruited new staff, including nurses and a clinical lead. Inspectors found enough staff available to provide safe and effective care.
“The service's new manager had recruited new staff, including nurses and a clinical lead, to the team.” from the report
Personalised support
Care records reflected people's likes, dislikes and preferred ways of receiving support. People and relatives were involved in assessments and care planning.
“People, their relatives and healthcare professionals participated in these assessments, which reflected people's choices.” from the report
Support with activities and relationships
People could take part in activities and were supported to keep in touch with relatives and friends. The home was planning to increase activity provision.
“People were supported to engage in activities such as bingo, sing-along sessions, pampering sessions, movie nights and gentle exercise.” from the report
Medicines records
seriousStaff did not always sign medicines administration records. The stock check suggested medicines had been given, but incomplete records meant the process was not properly safe.
“We found gaps in staff recording on MAR charts, so we undertook a physical check of the medicines in stock.” from the report
Care records had gaps
needs fixingInspectors found earlier gaps in records for repositioning, fluids and people's weights. New audits had addressed these issues, but the CQC said it would continue to monitor them.
“We reviewed people's repositioning records and found gaps in recording.” from the report
No registered manager
needs fixingThere was no registered manager in post at the inspection. The new manager intended 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 medicines administration records checked now, and what happens if a member of staff forgets to sign one?
- 02Can you show how turning, hydration and weight records are audited and followed up?
- 03Has the new manager registered with the CQC, and who is responsible for management until then?
- 04What changes have been made since the inspection to make sure the improvements are sustained?
- 05How many activity coordinators are now in post, and what activities are currently available?
This was an unannounced inspection prompted by concerns about medicines, people's weight, complaints and management, and it also checked infection prevention and control measures. This explanation was written from the published report of 3 February 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, September 2022
Rated Requires Improvement; inspectors found unsafe medicines records despite improvements in risks, staff training and management.
This was an unannounced focused inspection on 3 August 2022. Inspectors spoke with people, relatives and staff, and reviewed care records, medicines records, staff files, training records, audits and policies.
The home was rated Requires Improvement overall. Safe and Well-led were also Requires Improvement. Effective was rated Good. The main safety problem was medicines management. Records were not always accurate or up to date, including missing signatures and medicines missing from administration records.
Inspectors found that other safety risks were assessed and managed. There were enough staff, infection control arrangements were in place, and staff were trained and supported. Consent arrangements, care assessments, food and drink support, and access to healthcare were rated positively.
A new manager and deputy manager had been appointed, and quality systems were being improved. However, the home remained in breach of Regulation 12 because medicines were not managed safely. The provider was asked for an action plan and CQC said it would continue to monitor the home.
Risk management
People's safety risks were assessed, with clear information for staff about how to reduce those risks.
“Risks to people's safety were assessed and plans were in place to reduce and mitigate those risks.” from the report
Staff skills
Staff received regular training, supervision and an induction to help them carry out their roles.
“People received support from staff that had the knowledge and skills to undertake their roles.” from the report
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including the safe use of protective equipment.
“We were assured the provider was making sure infection outbreaks were effectively prevented or managed.” from the report
Improving management
A new manager and deputy manager were in place. The manager was identifying problems and taking prompt action where improvements were needed.
“Where improvements were identified as being required, prompt action was taken to address the concerns.” from the report
Medicines records
seriousSome medicines were not recorded on the correct administration records, and there were gaps where staff had not signed to confirm medicines were given. This created a risk that people might not receive medicines as prescribed.
“Appropriate records were not maintained regarding medicines management increasing the risk of people not receiving their medicines as prescribed.” from the report
Agency staff use
needs fixingThe home still relied heavily on agency staff. Recruitment was under way to provide more consistency and stability.
“At the time of our inspection there was still a high use of agency staff.” from the report
Management changes
minorThe management team and staff team were still relatively new. Inspectors had not yet been able to establish the impact of the new deputy manager.
“They were relatively new in post so we were unable to establish what impact this had had but we will review this at our next inspection.” from the report
- 01What has changed since the inspection to make sure every medicine is recorded on the correct administration record?
- 02How do you check each day that staff have signed for medicines that were given?
- 03How are new residents' medicines recorded when they first arrive?
- 04How are medicines prescribed to be given when needed recorded and checked?
- 05How are you reducing the use of agency staff and improving consistency in the staff team?
This was a focused inspection of Safe, Effective and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 7 September 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 Johns Nursing Home Limited
9 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at St Johns Nursing Home Limited →
- September 2022Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
Read what inspectors found at St Johns Nursing Home Limited →
- January 2022Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- September 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2015Goodup from Requires improvementSafe: GoodEffective: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 28 January 2011.
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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