CQC report explained · a nursing home
What the CQC found at St Joseph's Convent Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from harm, and accidents, incidents and unexplained injuries were recorded, reported and investigated. Medicines, staffing, recruitment and infection control were also judged safe, although moving and handling risk assessments were still described as generic.
- Effective?
- Good
- Care plans were personalised and up to date. Staff had training and support, people's legal rights and consent were considered, and their health, nutrition and access to healthcare were supported.
- Caring?
- Good
- People and relatives described staff as kind and compassionate. Inspectors saw people's privacy, dignity, choices, independence, cultural needs and religious needs being respected.
- Responsive?
- Requires improvement
- Care plans reflected people's individual needs and were updated when needs changed. However, activities were not consistently available, and the home could not show that people spending time in their rooms received regular social interaction.
- Well-led?
- Good
- Managers were approachable and staff felt supported. Quality checks and feedback systems had improved, although inspectors said some areas still needed more in-depth monitoring.
What inspectors found, April 2019
Rated Good overall, but inspectors found the home was not consistently responsive because activities were not always available or recorded.
The inspection was unannounced and took place on 22 January 2019. Inspectors spoke with people living in the home, relatives, staff and managers. They reviewed care plans, staff records, medicines records, complaints and quality checks.
Inspectors found people were safe. Incidents and unexplained injuries were now recorded, reported and investigated properly. Medicines were managed safely, staffing was sufficient, recruitment checks were completed, and infection control was effective.
Care was effective and caring. Staff were trained, kind and respectful. People's health, nutrition, choices, privacy and dignity were supported. Care plans were personalised and kept up to date.
The overall rating was Good. Responsive was rated Requires Improvement because people did not always receive the activities they wanted, especially people spending time in their rooms, and records did not always show what activities had taken place. Safe, Effective, Caring and Well-led were rated Good.
Safe medicines and staffing
Inspectors found medicines were managed safely and there were enough staff to meet people's needs. Recruitment checks were completed before staff started work.
“There were sufficient numbers of staff on duty at any one time to meet people's needs in a safe way.” from the report
Kind and respectful care
People and relatives gave positive feedback about staff. Inspectors saw privacy, dignity, personal choices and independence being respected.
“Staff were kind and respectful and they knew people well.” from the report
Personalised care planning
Care plans included people's health, life history, preferences and care needs. They were reviewed when people's needs changed.
“Care plans were sufficiently detailed and person-centred, giving members of staff and external professionals relevant information when providing care to people who used the service.” from the report
Improved management
Managers were approachable and involved people, relatives and staff in the home's development. Quality checks were better recorded and actions were followed up.
“Quality assurance measures were now more effective and systems were in place to check the quality of the care delivered by senior staff, registered managers and senior managers within the organisation.” from the report
Activities were not consistent
needs fixingSome people did not always get to planned activities, and the home could not evidence regular interaction for people who spent time in their rooms. Some electronic records did not show what activities had taken place.
“People were not always supported to take part in activities to help reduce social isolation.” from the report
Moving and handling assessments
needs fixingMost risk assessments were personalised, but moving and handling assessments were still generic. The manager said these would be reviewed.
“People's moving and handling risks were still seen to be generic although the registered manager said they would review them in line with other assessments.” from the report
Some staff needed more training support
minorStaff received training and support, but inspectors said some staff needed further help to make sure they understood the training they had received.
“People's needs and choices were assessed and staff received training and support though some staff needed more support to ensure they understood the training they had received.” from the report
- 01How do you make sure each person receives activities that match their interests and abilities?
- 02How often are people who spend time in their rooms offered social contact or activities, and how is this recorded?
- 03What action has been taken to make moving and handling risk assessments personalised?
- 04How do you check that staff understand and can apply the training they receive?
- 05How do you use people's feedback about activities to make changes?
This was an unannounced inspection covering all five CQC questions and the overall rating, with improvements also checked against concerns from the January 2018 inspection. This explanation was written from the published report of 4 April 2019 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 2018
Rated Requires Improvement; inspectors found kind care and enough staff, but serious gaps in safeguarding, medicines and oversight.
This was an unannounced inspection on 8 January 2018. Inspectors spoke with people living in the home, relatives, staff and a visiting professional. They observed care and checked care records, staff files, training records and quality checks.
People were treated with kindness, dignity and respect. Staff offered choices, food was enjoyed, healthcare support was available and the home was clean. Staffing and recruitment were also considered suitable overall.
However, unexplained injuries were not always investigated or reported to safeguarding authorities. Risk plans were not always followed, medicines were not always managed safely and some staff needed more help to understand their training. Care planning did not always reflect people's diverse needs, and quality checks had missed important problems.
The overall rating changed from Good at the last inspection to Requires Improvement. The home was not rated consistently good in four of the five areas. The report says improvements had started after the inspection, but inspectors could not yet judge whether they were firmly established.
Kind and respectful care
People described staff as kind and helpful. Inspectors saw staff communicate patiently, offer choices and protect people's privacy and dignity.
“Staff were kind, caring and compassionate with people.” from the report
Staffing and recruitment
People and staff generally felt there were enough staff. Recruitment checks were completed before staff worked with people.
“Staffing levels were sufficient to meet people's needs and staff had their suitability to work in a care setting checked before they began working with people.” from the report
Clean environment
The home and equipment were observed to be clean and hygienic. Staff used infection-control measures and audits were effective.
“People and their relatives told us that the service was clean and tidy.” from the report
Unexplained injuries
seriousSome bruising and skin tears were not investigated or reported to the local safeguarding authority. The home had not always taken action to reduce the chance of similar injuries happening again.
“some unexplained injuries such as bruising and skin tears had not been investigated and/or reported as a safeguarding concern.” from the report
Medicine safety
seriousInspectors found risks including an unlocked medicine fridge, incomplete records for creams and unclear instructions for some as-required medicines.
“These issues showed that medicines were not always safely managed.” from the report
Staff understanding
needs fixingSome staff needed more support to show they understood safeguarding and the Mental Capacity Act after training.
“some staff needed more support to ensure they understood their responsibilities under the MCA and safeguarding adult's procedures” from the report
Personalised care plans
needs fixingPeople's diverse needs were not always assessed and recorded accurately. Inspectors also found that one person had not been asked about their preference for the gender of staff providing personal care.
“people's diverse needs were not always fully assessed and planned for” from the report
- 01How are unexplained bruises, skin tears and other injuries now recorded, investigated and reported to the local safeguarding authority?
- 02How do you check that medicines, including topical creams and as-required medicines, are given and recorded as prescribed?
- 03How do you test that staff understand safeguarding procedures and the Mental Capacity Act after completing training?
- 04How will you assess and record each person's cultural, religious, sexuality and personal care preferences?
- 05What changes have been made to the activities programme and how do you respond when people find activities repetitive?
This was an unannounced comprehensive inspection covering all five CQC questions and the overall rating. This explanation was written from the published report of 13 February 2018 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 Joseph's Convent Nursing Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
Read what inspectors found at St Joseph's Convent Nursing Home →
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
Read what inspectors found at St Joseph's Convent Nursing Home →
- December 2015GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- July 2015
Registered with the Care Quality Commission on 2 July 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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