CQC report explained · a residential care home
What the CQC found at St Martins of Tours Housing - 158-162 New North Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, safeguarding concerns were reported more consistently, and infection control arrangements were suitable. They also found two recent medicine errors, followed by additional checks.
- Effective?
- Good
- This question was not assessed in this inspection.
- Caring?
- Good
- This question was not assessed in this inspection.
- Responsive?
- Good
- This question was not assessed in this inspection.
- Well-led?
- Good
- Inspectors found thorough management oversight, improved audits and clearer roles. The home was working more effectively with people and with health and social care professionals.
What inspectors found, March 2022
St Martins of Tours Housing - 158-162 New North Road was rated Good; inspectors found major improvements, with two recent medicine errors needing attention.
The inspection was unannounced and took place on 16 February 2022. One inspector spoke with one person using the service and members of the management team. They checked four people's risk assessments and medicines records, along with other records and audits.
The home was rated Good for Safe and Well-led. Inspectors found that safety had improved, incidents were being reported more consistently, risks were reviewed, and infection control arrangements were suitable.
There had been two recent medicine errors because staff did not follow clear instructions. The errors were identified quickly, people's safety was protected, and the home introduced a daily medicines handover check.
The previous rating had been Requires Improvement, although the last published rating was Unrated. Inspectors said the service had improved substantially over the previous two years.
Improved safety
The home had made substantial progress in reporting incidents and safeguarding concerns. Inspectors found that incidents had become less frequent and less severe.
“the level of incidents had continued to decline in both number and severity.” from the report
Risk management
Risk assessments covered people's individual support needs and risks in the community. Staff had person-centred guidance to follow, and the premises and equipment were checked.
“The service assessed the potential risks that people faced and responded to risks that were identified” from the report
Management oversight
The home had daily and weekly checks and a wider programme of audits. Inspectors found that action was taken when problems were identified.
“Checks were carried out daily and weekly in areas such as medicine stocks, care documentation and maintenance of the building.” from the report
Respect and equality
The home had clear expectations that people should be treated with dignity and respect. People's equality and diversity needs were recorded in their support plans.
“The provider had clear expectations, shared with people using the service and staff, about all people having the right to be treated with dignity and respect” from the report
Working with other services
Inspectors found that the home was reporting concerns more promptly and liaising regularly with community health and social care professionals.
“Care records showed that the service liaised with community health and social care professionals regularly” from the report
Recent medicine errors
needs fixingTwo recent errors happened because staff did not follow clear instructions for particular medicines. The home identified them quickly, took action and introduced a daily handover check, but families should ask how this improvement is being sustained.
“there had been two very recent errors which were the result of staff not following the clear instructions for providing particular medicines.” from the report
- 01What caused the two recent medicine errors, and what has been done to prevent the same mistakes happening again?
- 02How is the new daily medicines handover check recorded and reviewed?
- 03What action is taken when daily or weekly audits identify a problem?
- 04How are people involved in communal meetings and decisions about changes to the home?
- 05How does the home work with community health and social care professionals to support recovery and mental health needs?
This was an unannounced focused inspection of Safe and Well-led, including infection prevention and control; Caring, Effective and Responsive were not assessed in this report. This explanation was written from the published report of 4 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.
What inspectors found, November 2020
Inspected but not rated; inspectors found clear improvements in safety and management, but the previous Requires Improvement ratings were not changed.
This was a targeted inspection on 8 October 2020. It looked mainly at how the home responded to illegal drug use, anti-social behaviour and reporting concerns to the authorities. The inspector reviewed five care plans and risk assessments, complaints, infection control, safeguarding records and the improvement plan. They spoke with one resident, the registered manager and a team leader.
Inspectors found that risk assessments had improved and that people were receiving more support with addiction issues. Safeguarding concerns were being reported and incidents were declining. They also found better infection control, clean communal areas and suitable COVID-19 precautions.
Management checks had improved. Almost all of the improvement programme had been completed, and the local authority had removed the home from its provider concerns process and lifted the restriction on new placements.
The home was inspected but not rated at this visit. Safe and Well-led were both previously rated Requires Improvement, and those ratings were not reviewed. The other three areas were not covered by this targeted inspection.
Better risk planning
The five care plans and risk assessments inspected had been substantially improved. They identified risks linked to addiction and behaviour in more detail.
“Risk assessments were thorough and potential risks that people faced whether by their addiction issues or by displayed behaviour were identified.” from the report
Improved safeguarding
Concerns that might involve harm were being reported to the right authorities, including CQC. Inspectors said the number of incidents was falling.
“Incidents, including those that needed to be raised as potential safeguarding concerns were being reported and the level of incidents was declining.” from the report
Calmer environment
The resident spoken with said the home felt calmer and more relaxed than before, and that they felt at ease with other residents and staff.
“A person using the service told us that in the years that they have lived at the home they had not known things to be as calm and relaxed as they were right now.” from the report
Stronger management oversight
Inspectors found that management systems were now checking and reducing risks more effectively. Almost all of the improvement programme had been completed.
“The provider's quality monitoring systems were now effectively assessing, monitoring and mitigating the risks presented to people using the service and others.” from the report
Infection control
The home had COVID-19 precautions, regular cleaning and infection control procedures that inspectors considered suitable for the service.
“Appropriate infection control guidelines had been established that were suitable for a service of this type.” from the report
No new overall rating
needs fixingThe inspection only looked at specific concerns. The previous Requires Improvement ratings for Safe and Well-led remain in place because they were not reviewed.
“We have not given a new rating for this key question, as we have only looked at the part of the key question, we had specific concerns about.” from the report
- 01How are you currently monitoring illegal drug use and anti-social behaviour, and what were the most recent incidents?
- 02How often are residents' risk assessments and support plans reviewed, especially where addiction or behaviour risks are identified?
- 03How quickly are safeguarding concerns and serious incidents now reported to CQC and other relevant authorities?
- 04Which parts of the improvement programme were still incomplete at the inspection, and have they now been completed?
- 05What are the current ratings from the last full inspection for Effective, Caring and Responsive?
This was a targeted inspection of specific parts of Safe and Well-led; it did not assess the whole service, and the previous ratings were carried forward. This explanation was written from the published report of 4 November 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 Martins of Tours Housing - 158-162 New North Road
3 rated inspections over 5 years: the service has held its Good rating throughout.
- March 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Martins of Tours Housing - 158-162 New North Road →
- November 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
Read what inspectors found at St Martins of Tours Housing - 158-162 New North Road →
- November 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- October 2013
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 20 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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