CQC report explained · a residential care home
What the CQC found at St Luke's Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Most risks were managed well and staffing, safeguarding and infection control had improved. However, some medicines were not dated when opened, some as-required medicines lacked reasons on their records, and one care plan needed clearer seizure guidance.
- Effective?
- Good
- People's needs were assessed using recognised tools. Staff supported nutrition, hydration, health needs and people's rights to make choices.
- Caring?
- Good
- People were treated with respect and dignity. Staff involved people in their care and showed knowledge of their preferences and needs.
- Responsive?
- Good
- Care was personalised and people were supported with communication, family relationships, activities and complaints. Care plans were mostly detailed, although some information was still being updated.
- Well-led?
- Requires improvement
- Management had improved the culture and quality monitoring. However, some audits did not give a full picture of people's care, and inspectors needed to see improvements sustained over time.
What inspectors found, October 2023
Rated Requires Improvement; the home has left special measures after significant improvements, but medicines and quality checks still need work.
This was an unannounced follow-up inspection on 24 August and 11 September 2023. Inspectors spoke with people, relatives, staff and managers, observed care, and reviewed care records, risk assessments, medicines information and staff files.
The home had improved since its previous Inadequate rating. People generally received kind, personalised care. Their nutritional, health, communication and social needs were well supported. Staffing and safeguarding arrangements had also improved.
Some safety and management checks were not yet reliable. Medicines were not always dated when opened, some records did not explain why as-required medicines were given, and one care plan lacked enough guidance for managing a prolonged seizure. The home was no longer in breach of regulations, but inspectors wanted to see the improvements maintained over a longer period.
The overall rating is Requires Improvement. Safe and Well-led were Requires Improvement, while Effective, Caring and Responsive were Good. The home is no longer in Special Measures.
People felt safe
People said they felt safe and comfortable with staff. Safeguarding concerns were investigated and action was taken to reduce the risk of recurrence.
“People told us they felt safe with staff and felt comfortable with the way staff supported them.” from the report
Kind and respectful care
Inspectors saw positive interactions. Staff supported people's privacy, dignity, independence and personal choices.
“Throughout the inspection we saw positive interactions between people and staff.” from the report
Food and health support
People enjoyed the food and received help with eating and drinking. Staff worked with health professionals and followed guidance about people's health needs.
“People told us they enjoyed the food served to them.” from the report
Improved staffing
The home had recruited more regular staff. Inspectors found adequate staffing levels and staff who knew people's needs.
“The duty rosters we reviewed showed people were supported by adequate numbers of staff.” from the report
Medicine records
seriousSome medicines were not dated when opened, which could mean they were used after their safe period. Some as-required medicine records did not explain why the medicine was given.
“Not all medicines showed the date of opening.” from the report
A gap in risk guidance
seriousOne care plan did not give clear enough instructions for staff if the person had a prolonged seizure. The manager updated the plan after inspectors raised this.
“the information in their care plan lacked clear guidance for staff on how to manage an acute prolonged seizure.” from the report
Quality checks
needs fixingAudits did not always identify problems with medicines or show the full pattern of a person's care. The provider planned to improve its monitoring system.
“This meant trends in the person's responses may not be highlighted.” from the report
Improvements need to last
needs fixingThe new manager had made significant improvements, but inspectors said the home needed to show that these were maintained over a longer period.
“Further work is needed to ensure any improvements made at this inspection are sustained.” from the report
- 01How are you checking that every medicine is dated when opened and that as-required medicines have a clear reason recorded?
- 02What guidance is now in place for managing the person's prolonged seizure risk, and how do you make sure staff understand it?
- 03How are your audits being changed so they show when care is offered, refused or missed?
- 04What evidence can you show that the improvements made since the last inspection have continued?
- 05What is the timetable for the refurbishment work identified in the environmental audit?
This was an unannounced follow-up inspection that looked at all five key questions, the care and premises, infection control, people's records and staff files. This explanation was written from the published report of 19 October 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, May 2023
Rated Inadequate and placed in special measures; inspectors found serious problems with safety, medicines, staffing and management.
This was an unannounced focused inspection on 1 February, 22 February and 6 March 2023. Inspectors checked whether the home had met legal requirements after an earlier warning notice. They spoke with people, staff, a health professional and relatives, and reviewed care, medicines, training, recruitment and management records.
Inspectors found that risks from falls, fire safety, bed rails and skin damage were not always managed. Medicines were not safely administered or recorded. Some incidents were not investigated or reported. Many staff had not completed important training, and the home relied heavily on agency workers whose checks and inductions were not always recorded.
The home was rated Inadequate overall, with Safe and Well-led also rated Inadequate. These ratings had deteriorated from Requires Improvement at the previous inspection. Infection control, visiting arrangements and work under the Mental Capacity Act were found to be satisfactory, but the report says the home remained in breach of several regulations.
Infection control
Inspectors were assured that infection risks were being managed, including the use of protective equipment and responding to outbreaks.
“We were assured that the provider was preventing visitors from catching and spreading infections.” from the report
Family visits
People were able to see relatives regularly, and visitors were welcomed in line with current guidance.
“People told us they were able to see their relatives on a regular basis.” from the report
Mental Capacity Act
Inspectors found that decisions were being made within the principles of the Mental Capacity Act, with appropriate legal authorisations where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Unsafe risk management
seriousRequired safety measures were not always in place. Examples included missing bed bumpers and a sensor mat, incomplete evacuation information and people not always being repositioned as planned.
“The risks to people's safety were not well managed.” from the report
Medicines
seriousMedicines were not always checked, administered or recorded correctly. Audits did not reliably identify and resolve errors.
“People's medicines were not managed safely. Staff did not always follow safe administration practices.” from the report
Staff training and agency cover
seriousMany staff had not completed essential training. The home used 60 different agency workers over three months, with limited evidence of induction.
“Between November 2022 and February 2023, the duty rosters we viewed showed there had been 60 different agency staff undertaking shifts at the service.” from the report
Recruitment checks
seriousThe home could not show the required records for many agency workers. Staff identities did not always match agency records, and one profile lacked a DBS check.
“These poor practices meant the provider put people at risk as they did not have the required information to assure themselves fit and proper staff were employed” from the report
Weak management oversight
seriousQuality checks were incomplete and did not lead to action. The report says similar oversight problems had been seen at the previous three CQC inspections.
“This failure to provide effective governance of the service was a continued breach of Regulation 17” from the report
Inconsistent person-centred care
needs fixingFrequent changes in agency staff and contradictory care plan information meant people did not always receive consistent, personalised support.
“These two factors meant people did not always receive care in a person-centred way.” from the report
- 01What has been done to make sure each person's falls, bed rail, evacuation and skin care measures are in place every day?
- 02How are medicines now checked, administered and recorded, and how are errors followed up?
- 03How many agency staff are currently being used, and what checks, induction and training have been completed before they work here?
- 04What evidence can you show that staff have completed fire safety, moving and handling and safeguarding training?
- 05What changes have been made to the quality audits and provider oversight since this inspection?
This was a focused inspection of Safe and Well-led, while the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 25 May 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.
Every inspection of St Luke's Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- October 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2023Inadequatedown from Requires improvementSafe: InadequateWell-led: Inadequate
- August 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2021Requires improvementSafe: Requires improvementWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021
Registered with the Care Quality Commission on 22 March 2021.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.