CQC report explained · a nursing home
What the CQC found at St Lukes 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, August 2023
Rated Requires Improvement; inspectors found caring staff but weaknesses in records, staffing assurance and quality checks.
This was an unannounced focused inspection on 10 May and 12 June 2023. Inspectors looked at whether the home was safe and well-led. They spoke with people, family members, staff and health professionals, and checked care records, medicine records and management records.
People and families generally said staff were kind, knew people well and kept them safe. Medicines were mostly managed safely, safeguarding concerns were acted on, and staff worked with health professionals. However, some care plans and monitoring charts were incomplete or out of date. Records for some creams, fluid thickeners and medicines used for anxiety were also not always accurate.
The home received Requires Improvement for Safe and Well-led. The overall rating changed from Good at the previous inspection. The other three question ratings were not inspected and were carried forward from the previous inspection.
Kind and personal care
People, families and inspectors said staff knew people well and had developed positive relationships.
“The atmosphere is always pleasant and staff are always so welcoming.” from the report
Safeguarding
Staff had safeguarding training, knew what to do about concerns and made appropriate referrals.
“Safeguarding concerns were recorded and acted upon appropriately; this included referrals to relevant health or social care professionals.” from the report
New management plans
The new manager understood the role and had identified changes needed to improve quality and safety.
“The manager shared with us their current action plan which detailed all the areas they had identified as needing improvement.” from the report
Staffing pressure
needs fixingSome people, families and staff said staff were rushed or people had to wait for help. Inspectors were not always sure there would be enough staff if incidents occurred.
“We could not always be certain the current staff numbers would be enough to keep them and others safe if incidents occurred.” from the report
Medicine records
needs fixingRecords for topical creams and fluid thickeners were not always accurate. Records did not always show that other ways of reducing anxiety had been tried before giving an as-needed medicine.
“Charts used to show the administration of topical creams and fluid thickeners were not always completed accurately.” from the report
Weak quality checks
seriousAudits and checks did not identify all the problems found during the inspection. There was limited oversight of accidents and incidents.
“The provider had failed to maintain robust quality assurance systems and processes to drive continuous improvement.” from the report
- 01What changes have you made to ensure care plans contain detailed, current information about each person's risks and needs?
- 02How do you check that food, drink and hygiene charts are completed fully and accurately?
- 03How do you decide staffing levels when people need two or more staff, or when several people need help with meals?
- 04What checks now make sure topical cream, fluid thickener and as-needed medicine records are accurate?
- 05How do you review accidents and incidents so that lessons are learned and problems do not happen again?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 8 August 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, February 2022
Rated Good; inspectors found safe, kind and well-organised care, with agency staffing and some maintenance still being addressed.
This was the first full inspection of the newly registered service. It was unannounced and took place on 22 and 23 December 2021 and 19 January 2022. Inspectors spoke with six residents, 11 relatives, seven staff members and health professionals. They also observed care and checked care, medicines, staff and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff to provide safe care, well-managed medicines, suitable support with food and healthcare, respectful interactions and person-centred care plans.
The home had good infection prevention arrangements during the COVID-19 pandemic. Complaints, incidents and quality checks were monitored. Inspectors noted that the home used a high number of agency staff, some agency training was still being completed, and parts of the building needed better maintenance.
Kind and respectful care
Inspectors observed calm, positive interactions. Relatives also described staff as caring, supportive and respectful.
“We observed some lovely interactions between staff and the people they supported, they were knowledgeable of each person.” from the report
Safe medicines practice
Medicines were stored and administered safely. Records were complete and staff were assessed as competent, with further training for agency staff still in progress.
“Records for the administration of medicines were person centred and complete.” from the report
Infection control
The home had additional cleaning procedures, audits, COVID-19 training and regular testing. Inspectors were assured that infection prevention and control was being managed well.
“We were assured that this service met good infection prevention and control guidelines” from the report
Person-centred planning
Support plans recorded people's needs, choices and communication preferences. Relatives were involved in planning and were kept informed.
“Each person's support plan was written in a way which was meaningful for them and showed they were respected as an individual” from the report
Reliance on agency staff
needs fixingThe home used a high number of agency staff during the change from the previous provider. It was recruiting permanent staff, and some agency staff still needed to complete medicines training.
“The service used a high number of agency staff due to a movement of staff from the previous provider being transferred over to the service.” from the report
Some areas needed maintenance
minorThe home was clean, tidy and safe, but some walls and door frames had scrapes and were less well maintained than other areas.
“Some areas were more well maintained than others such as scrapes seen to some walls and doors frames.” from the report
Manager registration
needs fixingThe report said there was no manager registered with the CQC at the time. The current manager planned to apply for the permanent post, while a registered manager was absent.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01How many permanent staff are now in post, and how often is agency staff still used?
- 02How do you check that agency staff have completed medicines training and understand residents' individual needs?
- 03What work has been completed on the scrapes to walls and door frames, and what maintenance remains?
- 04Has a permanent manager been appointed and registered with the CQC since this inspection?
This was an unannounced first full inspection covering all five CQC questions, including infection prevention and control and both the premises and care provided. This explanation was written from the published report of 4 February 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 Lukes Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022GoodSafe: GoodWell-led: Good
- January 2021Inspected but not ratedSafe: Inspected but not rated
- November 2018Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2016Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019
Registered with the Care Quality Commission on 18 November 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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At least 100 live-in carers within about an hour of Halton
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.
Most charge £980 to £1,260 a week. 89 can care for a couple. 10 years' experience on average.
“It was clear that she genuinely cared and her warm approach really helped put our minds at ease.”
“He developed a close affinity with Terence, spending time talking with him before he retired to bed and looking after his needs during the night.”
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.