CQC report explained · a nursing 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.
What inspectors found, September 2021
Rated Requires Improvement; inspectors found kind care, but records, risk management and medicines systems were not reliable enough.
Inspectors visited on 29 June 2021 and reviewed information and records up to 13 August 2021. They spoke with people, relatives were represented through feedback, staff and managers, and observed care. They also checked medicines, care records, staffing, training, complaints, infection control and management checks.
People generally said they felt safe and were treated kindly. Staff knew people well, respected their choices and supported their privacy and dignity. Staffing levels were considered enough overall, the home was clean, and infection control arrangements followed current guidance.
However, care records did not always accurately describe people's risks, care needs, food and fluid intake or activities. Some medicines instructions were unclear, and some records did not show whether care had been completed or concerns such as pain had been followed up. The home had begun correcting some problems during the inspection, but inspectors said further work was needed.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were rated Requires Improvement. Caring was rated Good. The home breached Regulation 17 because its systems did not reliably identify problems or keep accurate, up-to-date records.
Kind and respectful staff
People described staff positively, and inspectors saw kind and caring interactions. Staff respected privacy, dignity and people's choices.
“All interactions we observed were kind, caring, positive and appropriate.” from the report
People's choices respected
People were involved in decisions about their care and could choose things such as when to get up or go to bed. Staff supported people in the least restrictive way possible.
“People told us they made their own choices and decisions.” from the report
Enough staff overall
Inspectors found staffing levels were generally suitable for people's needs, and the provider reviewed staffing when people's needs changed.
“Overall, there were enough staff to care for people safely.” from the report
Infection control
Inspectors were assured that the home followed arrangements for preventing and managing infections, including use of protective equipment and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Supportive management culture
Staff said managers were approachable and that communication and teamwork were good. People said residents' meetings led to changes.
“Staff spoke of excellent teamwork and communication in the service.” from the report
Incomplete risk information
seriousSome people had bed rails or behaviours that needed risk plans, but detailed guidance for staff was missing. This could make it harder to manage risks consistently.
“People's care records did not always contain detailed risk assessments.” from the report
Medicines instructions
seriousSome instructions for medicines given when needed were unclear or conflicted. The home corrected some issues during the inspection, but inspectors said these changes needed to be sustained.
“Some instructions for how to administer PRN medicines were not clear and at times in conflict” from the report
Care records were not dependable
needs fixingRecords did not always show when care was given. There were gaps in records about position changes, fluids and food, and some information did not match people's needs.
“Personal care records were not always accurately completed by staff.” from the report
Follow-up of pain
needs fixingTwo people's records mentioned pain but did not show that this had been followed up or acted on. The manager said this would be reviewed.
“There was no evidence of follow up or action in response to this for two people whose records we reviewed.” from the report
Management checks missed problems
seriousThe home's audits covered several areas but did not identify the shortfalls found by inspectors. This resulted in a breach of good governance requirements.
“Audits completed in the service had not identified this.” from the report
Some slower call responses
minorAlthough staffing was enough overall, some people and a staff member said responses could take longer at busy times, especially if the home was full.
“Calls aren't answered as quick as they could be.” from the report
- 01What has changed in the electronic care planning system since the inspection, and how do you check that records are accurate?
- 02How are risks such as bed rails, choking or behaviours recorded and explained to staff now?
- 03How are medicines given when needed reviewed with the GP, and how do you prevent conflicting instructions?
- 04How do you record food, fluids, position changes and activities, including for people who spend time in their rooms?
- 05What action was taken after the Regulation 17 breach, and what evidence can you show that the problems have been fixed?
This was a planned inspection covering all five key questions and infection prevention and control; inspection activity ran from 29 June to 13 August 2021, with a visit to the home on 29 June. This explanation was written from the published report of 8 September 2021 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, September 2020
Inspected but not rated overall; inspectors found kind, well-led care, but medicines records and some safety records needed improvement.
This was a focused inspection during August 2020. Inspectors looked only at Safe and Well-led, so the home was not given an overall rating. The inspection involved speaking with people, relatives and staff, observing care, and reviewing medicines, care, staffing and management records.
The Safe rating was Requires Improvement. Medicines were generally managed safely, but records for prescribed creams and thickening agents were not always accurate. Inspectors also found some gaps in fluid records, medicine temperature checks, infection-control practice and recruitment records.
The Well-led rating was Good. Inspectors found approachable management, kind staff, effective audits and a clear commitment to person-centred care. The report says this was the first inspection since the service registered under the new provider.
Kind and respectful care
People and relatives said they felt safe. Inspectors saw positive, kind interactions and care given at a pace that suited people.
“Staff interactions were positive and kind. People were given care and support at a pace that suited them.” from the report
Good management oversight
The provider and manager used audits, checks and feedback to monitor the service. They responded openly when inspectors identified issues.
“The provider and management team continually monitored the standard of service and acted where improvements could be made.” from the report
Clean environment and infection controls
The home was clean, had no unpleasant smells and had enough protective equipment. Staff had a good understanding of COVID-19 infection-control guidance overall.
“The environment was clean and there were no malodours. All the staff worked hard to maintain cleaning standards in the service.” from the report
Staffing and risk support
Inspectors found enough staff to meet people's needs and clear risk assessments covering areas such as falls, mobility and skin care.
“There were enough staff to meet people's needs. People and their relatives said they had no concerns about staffing levels.” from the report
Medicine records
seriousDirections for prescribed creams were not always clear, and records did not always show that creams had been used as prescribed. One person received more than the prescribed dose of a cream.
“One person had received more than the prescribed dose of their cream. The registered manager addressed this at the time of the visit and reported the error to the person's GP.” from the report
Thickening-agent records
needs fixingStaff did not record every dose of thickening agent, although the clinical lead said it had been used as prescribed. Inspectors recommended following NICE medicines guidance.
“Staff did not record the administration of every dose of thickening agent.” from the report
Fluid monitoring
needs fixingFluid-intake records were not always completed accurately. The manager took immediate action to put a new system in place.
“However, we saw staff did not always accurately complete records of fluid intake.” from the report
Infection-control details
needs fixingCorrect PPE-handling guidance was not followed on a small number of occasions. Some policies had also not been fully updated to reflect the latest government guidance.
“On a small number of occasions, we observed the correct guidance regarding the handling of PPE was not followed.” from the report
Recruitment record
minorOne staff record did not show that a reference from the last employer had been obtained, as required by the provider's policy.
“One staff member's records indicated the provider had not followed their policy of gaining a reference from the last employer.” from the report
- 01What changes have you made to ensure prescribed creams and thickening agents are given and recorded exactly as prescribed?
- 02How do you now check that fluid-intake records are completed accurately for people who need monitoring?
- 03Have all infection-control policies been updated to reflect the latest guidance, and how do you check PPE is handled correctly?
- 04How do you check medicine storage temperatures and make sure all required recruitment references are obtained?
- 05What improvements have been made since the focused inspection, and when will they be reviewed?
This was a focused inspection of Safe and Well-led only; the other three key questions were not assessed and no overall rating was given. This explanation was written from the published report of 22 September 2020 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
Each visit the CQC has published, newest first, back to the day the home was registered.
- September 2021Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2020Inspected but not ratedSafe: Requires improvementWell-led: Good
- March 2019
Registered with the Care Quality Commission on 26 March 2019.
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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