CQC report explained · a nursing home
What the CQC found at St Katharine's House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks, medicines, recruitment and infection control were managed well, although mental capacity assessment records were not always decision-specific.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- Care was personalised and reflected people's needs, preferences and routines. People had access to activities, communication support and complaint processes.
- Well-led?
- Good
- Inspectors found clear leadership, teamwork and quality checks. The management team had made significant improvements and worked with external health and social care professionals.
What inspectors found, March 2023
St Katharine's House is rated Good; inspectors found safe, personalised care and strong management, but mental capacity records and staffing deployment needed improvement.
Inspectors visited the home without notice on 21 February 2023. They spoke with people, relatives, staff and healthcare professionals. They observed care, reviewed care and medicine records, and checked recruitment, complaints, incidents and quality checks.
The home was rated Good overall. Safe, Responsive and Well-led were rated Good. People said they felt safe, received personalised care, had activities available and could raise concerns. Medicines were managed safely and infection controls were effective during a COVID-19 outbreak.
Inspectors found that some mental capacity assessments were not recorded clearly enough. Staff were also very busy at some times, especially on the nursing unit. The home had made improvements since the previous inspection, when the overall rating was Requires Improvement.
This was a focused inspection. Effective and Caring were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Personalised care
Care plans reflected people's individual needs and preferences. Staff knew people well and updated plans when needs changed.
“People received personalised care and support specific to their needs, preferences and routines.” from the report
Safe medicines
People received medicines as prescribed. Staff were trained, their competence was checked, and records were accurate.
“People received their medicines as prescribed and the service had safe medicine storage systems in place.” from the report
Activities and relationships
People could take part in activities such as walks, pet therapy, exercise, arts and crafts. One-to-one interaction was available for people who could not join group activities.
“People had access to activities led by an enthusiastic activities coordinator which included walks and strolls outside in good weather and a sensory garden.” from the report
Open management
Inspectors found a positive, open culture. The management team used feedback, audits and meetings to make improvements.
“The service had a positive culture that was person-centred, open and inclusive.” from the report
Mental capacity records
needs fixingSome records on the dementia unit did not clearly relate each assessment to a particular decision. Inspectors recommended that the home improve this practice.
“However, we found some of the recording of mental capacity assessments on the dementia unit could be improved to ensure they were decision specific.” from the report
Staff deployment at busy times
needs fixingStaff were often busy, and inspectors found that deployment could be improved on the nursing unit during busy periods. The manager later reported changes intended to improve this.
“However, we saw staff deployment could be improved on the nursing unit during busy periods.” from the report
- 01How are mental capacity assessments now recorded for each specific decision?
- 02How many staff are planned for the nursing unit during mornings, lunchtime and other busy periods?
- 03Have the changes to protected mealtimes, coaching hours and handover times improved staffing on the nursing unit?
- 04How will you make sure care records remain accurate while staff are getting used to the electronic recording system?
- 05Which ratings for Effective and Caring came from the previous inspection?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 29 March 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, July 2019
Rated Requires Improvement; inspectors found kind and effective care, but wanted stronger assurance that improvements would last.
This was an unannounced planned inspection on 30 May 2019. Inspectors spoke with people, relatives and staff, observed care and reviewed care, medicines, recruitment and management records.
The home had improved since its previous Inadequate rating. Inspectors found people were safe at the time, medicines were managed safely, staffing was sufficient and care plans and infection control had improved.
People were treated with kindness and respect. They enjoyed food and activities, had access to health professionals and were supported to make choices. Complaints were investigated in line with the provider's policy.
The overall rating was Requires Improvement. Safe, responsive and well-led were Requires Improvement, while effective and caring were Good. The home had been in Special Measures, but it was no longer in Special Measures after this inspection.
Kind and respectful care
People were treated with kindness, dignity and respect. Staff listened to people's choices and supported their independence.
“Throughout the inspection we saw many kind and caring interactions.” from the report
Enough staff
Inspectors found enough staff to meet people's needs, and staff responded promptly to requests for support.
“There were sufficient staff deployed to meet people's needs.” from the report
Safer medicines and infection control
Medicines were stored and recorded safely. The home had also improved its bathrooms, cleanliness and infection control practice.
“Medicines were stored safely and securely in line with legislative requirements.” from the report
Personalised care and activities
Care plans included people's histories, preferences and communication needs. People could take part in group or one-to-one activities, including a dementia café.
“People had access to a range of activities that included group activities and one to one time.” from the report
Improved management systems
The new management team introduced audits and action plans covering areas such as care plans, medicines, training and infection control.
“The management team had implemented a range of quality assurance systems that enabled the provider and manager to monitor and improve the quality of the service.” from the report
Improvements may not last
seriousThe CQC found the home was safe during the visit but had limited assurance that the improvements would continue. This created an increased risk that people could be harmed.
“Although the service was safe at the time of the inspection there was limited assurance about the sustainability of the improvements made.” from the report
Responsive care needs stronger assurance
needs fixingPeople's needs were being met and their care plans were current. However, inspectors could not be sure that the improvements in personalised care would be sustained.
“Although at the time of the inspection people's needs were being met, we could not be sure the service could sustain these improvements.” from the report
Management arrangements
needs fixingThe home did not have a manager registered with the CQC at the inspection. An application had been submitted.
“The service did not have a manager registered with the Care Quality Commission.” from the report
Culture still needed embedding
needs fixingInspectors saw positive leadership and teamwork, but said the management culture needed to become firmly established so it consistently supported high-quality care.
“The culture they created needed to be embedded to ensure it supported the delivery of high-quality, person-centred care.” from the report
- 01What checks are now in place to make sure the improvements in safety and personalised care continue?
- 02What is the progress of the application for the home manager to become registered with the CQC?
- 03How do you check that care plans remain accurate when people's needs or communication needs change?
- 04What actions have been taken to make sure night staff understand emergency situations, including fire procedures?
- 05How are people and relatives' views used to improve the home, including changes to the garden and activities?
This was an unannounced planned inspection covering all five key questions and checking progress after the previous Inadequate rating and regulatory breaches. This explanation was written from the published report of 18 July 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.
Every inspection of St Katharine's House
7 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- March 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2018Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: InadequateWell-led: Inadequate
- February 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 7 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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