CQC report explained · a nursing home
What the CQC found at St Josephs Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2022
Rated Requires Improvement; the home had improved since an Inadequate rating, but fire safety checks, records and staff induction still needed attention.
The inspection was unannounced and took place on 26 July 2022. One inspector spoke with people, relatives and staff, and reviewed care plans, medicine records, staff files and management records.
The home had improved since its previous inspection. People told inspectors they felt safe, were treated kindly and had enough food. Medicines, safeguarding, recruitment, care planning and support with health needs had improved.
However, three fire doors did not close properly during a test. Some safety certificates and health and safety records could not be found, and paper records were disorganised. New staff did not yet have a formal induction programme.
The overall rating was Requires Improvement. Safe, Effective and Well-led were also rated Requires Improvement. The home was no longer rated Inadequate and was no longer in Special Measures, but CQC asked for an action plan and will continue to monitor progress.
People felt safe
People told inspectors they felt safe. Staff understood safeguarding duties and appropriate action had been taken when concerns were raised.
“People told us they felt safe and had no concerns about their personal safety of the care they received.” from the report
Safer recruitment
The home had improved its recruitment checks. Records showed appropriate employment, reference, criminal record and professional registration checks.
“People were protected by safe recruitment processes.” from the report
Medicines were managed safely
Trained nurses gave medicines, records were completed properly and people received medicines on time, including time-specific medicines.
“At this inspection improvements had been made and medicines were managed safely.” from the report
Kind and respectful care
People, relatives and staff gave positive feedback about the care and the manager. Inspectors observed respectful, compassionate and supportive interactions.
“People were treated with respect and dignity and spoke highly of the service they received.” from the report
Food and mealtimes
People's dietary needs, allergies and swallowing risks were supported. People said they had plenty to eat, and inspectors saw positive and social mealtimes.
“People had a positive mealtimes experience.” from the report
Fire safety checks
seriousThree fire doors failed to close during a planned alarm test. One was affected by a carpet, one was wedged open and another had a faulty closing mechanism. The home took immediate action.
“At inspection three fire doors failed to close during a planned fire alarm test.” from the report
Disorganised safety records
needs fixingQuality checks had not identified the fire safety concerns. Some safety certificates could not be found, and paper health and safety records were disorganised.
“We were not assured as to the accuracy of fire safety logs and checks because some safety inspection certificates could not be found at inspection.” from the report
Formal induction not yet in place
needs fixingNew staff did not have access to a formal induction programme. The provider was developing one, including the opportunity for new care staff to complete the Care Certificate.
“New staff did not have access to a formal induction programme.” from the report
Dementia-friendly environment
minorThe corridors did not help people living with dementia with orientation or communication. The manager said changes were being considered using best practice guidance.
“For people living with dementia, the decoration in the corridors did not enhance orientation or communication.” from the report
- 01How are you now checking that every fire door closes properly, and where are the safety certificates kept?
- 02What formal induction programme is now given to new staff, and can new staff complete the Care Certificate?
- 03How are the new electronic care plans being checked to make sure they remain current and are used fully by staff?
- 04What changes have been made to improve the corridors for people living with dementia?
- 05What action plan did you provide to CQC, and what progress has been made since this inspection?
This was an unannounced focused inspection of Safe, Effective and Well-led; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 6 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.
What inspectors found, March 2022
Rated Inadequate and placed in special measures; inspectors found serious risks in safe care, consent, safeguarding, recruitment and management.
This was an unannounced focused inspection on 21 October 2021. Inspectors spoke with people, relatives and staff, reviewed care and medicines records, checked recruitment files and examined management information. They looked only at Safe, Effective and Well-led.
Inspectors found that risks such as falls, choking and health conditions were not always assessed or managed. Safeguarding concerns were not always reported or investigated. Medicines records and checks on new staff were also not consistently safe. The home was not following the legal rules on consent and mental capacity.
The overall rating fell from Good in 2017 to Inadequate. Safe and Well-led were rated Inadequate, and Effective was rated Requires Improvement. Caring and Responsive were not inspected during this visit, so their previous ratings were carried forward.
Kind and familiar staff
People and relatives spoke positively about the staff. Inspectors found that staff knew people well and understood how to pass on concerns at handovers.
“People and their relatives told us they felt safe and people were cared for by kind and caring staff who understood their needs.” from the report
Food and fluids
People were supported to choose where to eat and were offered suitable food and drinks. Staff knew about people's dietary needs and preferences.
“People were supported to eat and drink enough and maintain a balanced diet.” from the report
Access to health professionals
The home worked with GPs and specialist health professionals. Inspectors found that people could receive support with appointments and changes in their health.
“Staff worked frequently with other agencies and sought their input and advice.” from the report
Infection control
Inspectors found that the home used protective equipment correctly, tested people and staff, and kept bedrooms and communal areas clean. Visits were arranged with infection control measures.
“We were assured the provider was using PPE effectively and safely.” from the report
Spiritual support
People could attend Mass in the chapel or listen to it in their rooms. Inspectors said people's spiritual and religious needs were being met.
“Mass was held each day and people living at the home were invited to attend.” from the report
Unmanaged safety risks
seriousCare records did not give staff enough information to manage risks. Inspectors found gaps involving falls, choking, diabetes and unexplained bruising.
“The provider had failed to ensure that risks were appropriately identified, assessed and mitigated to keep people safe.” from the report
Safeguarding failures
seriousAllegations of abuse were not always reported to the local authority or CQC. Incidents were not always investigated to prevent them happening again.
“The provider had failed to act appropriately when a person had made an allegation of abuse.” from the report
Medicines not fully controlled
seriousNurses had not been assessed for medicines competence. Records did not always explain when as-required medicines should be given or prove that time-specific medicines were given at the right time.
“Medicines were not always managed, administered and stored safely.” from the report
Unsafe recruitment checks
seriousSome new staff started work before all required references and DBS checks had been completed. One person worked independently without a DBS check or a suitable risk assessment.
“The provider had failed to operate robust recruitment procedures and ensure that relevant pre-employment checks for new staff were undertaken.” from the report
Consent and legal safeguards
seriousCapacity assessments and DoLS records were missing or out of date. The home could not show that restrictive practices, such as bedrails, had been lawfully agreed.
“The provider had failed to consider and implement the principles of the Mental Capacity Act (2005).” from the report
Weak management oversight
seriousQuality systems did not identify important problems or ensure that lessons were learned. There was no registered manager and staff supervision and training records were incomplete.
“Management systems were not effective and risks to people had not always been identified, assessed or mitigated.” from the report
- 01What action has been taken to make sure every resident's risks, including falls, choking and health conditions, are assessed and reviewed?
- 02How are safeguarding allegations and serious incidents now reported, investigated and used to prevent recurrence?
- 03How do you check that medicines are reviewed, given at the prescribed times and administered only by staff whose competence has been assessed?
- 04Are all staff now employed only after the required references and DBS checks, and can you show how this is recorded?
- 05How are mental capacity assessments, best-interest decisions and DoLS applications kept up to date?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 9 March 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 Josephs Nursing Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- September 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022InadequateSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- April 2021Inspected but not ratedSafe: Inspected but not rated
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- July 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- May 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 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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