CQC report explained · a nursing home
What the CQC found at St Joseph's - Manchester
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing levels, risk management, maintenance, cleanliness and most medicines systems were good, but some medicines processes needed improvement.
- Effective?
- Good
- People received good support with food, health care, oral health and communication. Staff were trained, and care was planned around people's needs, choices and capacity.
- Caring?
- Outstanding
- Staff treated people with exceptional kindness, dignity and respect. They supported people's independence, relationships, beliefs and families, including during bereavement.
- Responsive?
- Outstanding
- Care was highly personalised and adapted to people's interests, communication needs and wishes. Activities, friendships, faith support and end-of-life care were particularly strong.
- Well-led?
- Outstanding
- Inspectors found exceptional leadership, an open culture and effective quality checks. The home listened to people and used feedback and partnerships to improve care.
What inspectors found, December 2019
Rated Outstanding overall; inspectors found exceptionally caring, responsive and well-led care, with some medicines processes needing improvement.
Inspectors visited on three dates. The first visit was unannounced. They spoke with 15 people, five relatives, staff, volunteers and health professionals. They also reviewed care plans, medicines records, staff files and management records.
The home was rated Outstanding overall. Caring, Responsive and Well-led were Outstanding. Safe and Effective were Good. Inspectors found kind and personalised care, good healthcare support, varied activities and strong leadership.
There were two medicines shortfalls. Some prescribed creams were not stored using best practice, and some people on the residential unit did not have the required as-needed medicines protocols. The home was told about these issues and said it would put them right. No harm was found.
Personalised support
Staff knew people's routines, interests, communication needs and preferences. Care plans included life histories and detailed information about daily life.
“The service provided an exceptionally personalised service for individual people that met their specific needs, preferences and wishes.” from the report
Activities and relationships
The home helped people maintain family and community links and develop friendships. Activities were varied and adapted so people could choose whether to join in.
“The staff and volunteers were exceptional at helping people to maintain and develop relationships with their families, friends and the wider community.” from the report
End-of-life support
Inspectors found compassionate support for people approaching the end of life and for their relatives. Religious and spiritual wishes were respected.
“The approach to and delivery of care and support for people at the end of their lives was exceptional.” from the report
Leadership and improvement
The home had experienced leaders, strong quality checks and an open approach to learning from incidents. People, relatives, staff and professionals were involved in improving the service.
“There was a well-established and fully embedded governance and quality assurance framework in place.” from the report
Storage of prescribed creams
needs fixingSome prescribed creams were not stored using best practice. Inspectors found no evidence of harm, and the issue was raised with the home so action could be taken.
“Not all best practice process was in place, particularly regarding the storage of some prescribed creams.” from the report
As-needed medicines protocols
needs fixingSome people on the residential unit did not have an as-needed medicines protocol where one was necessary. The home said this would be corrected.
“Not everyone on the residential unit had a PRN protocol in place where necessary.” from the report
- 01What changes were made to the storage of prescribed creams after the inspection?
- 02Does my relative have a clear protocol for any as-needed medicines, and how is it kept up to date?
- 03How did the building works affect people's daily routines, activities and access to facilities?
- 04How will you support my relative's faith, cultural needs, relationships and preferred activities?
- 05How are relatives involved in care planning and decisions when a person cannot make a decision themselves?
This was a planned inspection covering all five key questions, including the premises and care provided; the first visit was unannounced and later visits gathered further feedback. This explanation was written from the published report of 14 December 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 2017
Rated Good; inspectors found safe, kind and person-centred care, with some records and communication needing improvement.
The inspection took place on 26 and 27 October 2016. The first day was unannounced. Inspectors spoke with people living at the home, relatives, staff and healthcare professionals. They observed care and checked care records, medicines, recruitment files, training records and quality checks.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found enough staff on duty, detailed risk assessments, safe medicines systems, skilled staff and good access to healthcare. People and relatives described staff as kind and caring.
Care plans were personal to each resident and included their choices and preferences. Activities, family involvement and religious support were strong. Inspectors also found some issues, including one food intolerance not being acted on, incomplete paperwork for covert medicines, and less regular supervision for some night staff.
Kind and respectful care
Inspectors saw staff treating people with kindness, dignity and respect. People and relatives also described the staff as caring and attentive.
“We saw that people were respected by staff and treated with kindness.” from the report
Personalised care
Care plans included people's likes, dislikes, routines and choices. Staff knew people well and used this information in daily care.
“Care plans were written in a person-centred way and staff used these plans to support and involve people” from the report
Good healthcare links
The home had weekly GP sessions and made referrals to other health professionals when needed. Inspectors said medicines were reviewed promptly.
“This proactive approach meant that people's medicines were reviewed in a timely manner” from the report
Activities and family involvement
People had access to trips, events and other activities. Relatives were welcomed and encouraged to remain involved.
“People's access to activities was very good; we saw that people were supported to get out and about on organised trips.” from the report
Strong leadership and monitoring
The manager was visible and staff felt supported and listened to. Audits and feedback systems were used to monitor the service.
“The systems and mechanisms in place to audit and monitor the service were robust.” from the report
Food intolerance information
needs fixingOne person said they were still offered food they had reported as causing an intolerance. The report said preferences and dislikes should be recorded and shared more reliably.
“I have written this down and passed it on but this did not seem to make any difference.” from the report
Incomplete medicines paperwork
needs fixingPaperwork was not always completed for decisions about covert medicines. The manager said this would be corrected.
“We did identify that this paperwork was not always completed, for example in the covert administration of medicines for an individual.” from the report
Night staff supervision
minorMost staff received regular supervision, but this was less consistent for night staff. The home said it would address this urgently.
“There were some slippages with night staff whose supervisions were not as regular.” from the report
Staffing pressure
minorInspectors found enough staff on the days visited, but some staff said shortages could be stressful and could leave less time for care planning and professional liaison.
“It is stressful sometimes due to the shortage of staff.” from the report
- 01How will you make sure food intolerances and other dietary preferences are recorded and shared with every relevant member of staff?
- 02How do you record and review best-interest decisions when medicines are given covertly?
- 03How often do night staff receive supervision, and how do you check that this is happening regularly?
- 04How do you ensure staffing levels leave enough time for care planning and contact with healthcare professionals?
- 05What activities are available when the activities coordinator is away?
This was a planned inspection of the overall service and all five CQC questions, with the first day unannounced. This explanation was written from the published report of 21 February 2017 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 - Manchester
2 rated inspections over 3 years: the service has improved, from Good to Outstanding.
- December 2019Outstandingcurrent ratingup from GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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