CQC report explained · a nursing home
What the CQC found at St Matthews Limited - The Avenue
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2022
St Matthews Limited - The Avenue was rated Good; inspectors found safe, responsive and well-led care, with some improvements still needed.
The inspection was unannounced and took place on 29 November and 8 December 2021. Inspectors spoke with people, relatives and staff, and reviewed care records, medicine records, recruitment files and quality monitoring records.
The home supported 31 older people with dementia and/or mental health needs. Inspectors found enough staff, safe medicine systems, good infection control and suitable risk assessments. People's care plans were detailed and regularly reviewed.
The home was rated Good overall, with Good ratings for Safe, Responsive and Well-led. The report says people's needs were met through good organisation and delivery, and that the service was consistently managed and well-led.
Safe staffing and recruitment
Inspectors found enough staff to meet people's needs and keep them safe. Recruitment records showed the required checks had been completed.
“People were supported by sufficient numbers of staff who had undergone a robust recruitment process.” from the report
Safe medicines
Medicines were stored, given and monitored safely. Staff received training and regular checks of their competence.
“Medicines were stored and administered safely, and staff were trained to support people effectively.” from the report
Personalised care planning
Care plans gave staff detailed information about people's physical, mental, emotional and social needs. Plans were reviewed and adapted where needed.
“People's needs were assessed, kept under review and support plans were adapted to suit people's individual needs.” from the report
Quality monitoring
The home used audits, feedback and incident reviews to identify improvements. Information about learning was shared with other homes run by the provider.
“Governance systems, including quality assurance policies and practices, were embedded to ensure good outcomes for people.” from the report
Recent staff changes
needs fixingA relative raised concern about a large change in staff, which can affect continuity for people with dementia. The manager said the situation had stabilised and that the deputy manager was supporting the staff team.
“On the negative side, the changes of staff seem to be quite dramatic which is not good for people with dementia.” from the report
Minor complaints records
minorThe manager was asked to record complaints that might otherwise be treated as minor. This would help identify repeated issues and resolve them quickly.
“We recommended the registered manager keep a record of what would be considered 'minor' complaints.” from the report
End of life care plans
needs fixingThe manager recognised that end of life care plans needed to be assessed and agreed more proactively with people or their relatives. Further staff instruction and training was planned.
“The registered manager had recognised further work was needed to ensure people's end of life care plans were proactively assessed and agreed with them, or a close relative where people were unable to do this.” from the report
- 01How have you maintained staffing stability since the inspection, and how do you limit the effect of staff changes on people with dementia?
- 02How do you now record and review minor complaints?
- 03How are end of life care plans discussed and agreed with residents or their relatives?
- 04How are falls and other unwitnessed incidents reviewed, and what changes have been made to reduce the chance of them happening again?
- 05How will you keep families involved in reviewing each person's care plan?
This inspection covered Safe, Responsive and Well-led; the report does not give separate ratings for Effective or Caring, and infection prevention and control was also examined. This explanation was written from the published report of 13 January 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, December 2019
St Matthews Limited - The Avenue was rated Good; inspectors found safe, kind and personalised care, with some care records still needing improvement.
This was an unannounced planned inspection. Inspectors visited the home on 25 November 2019 and spoke with people, relatives and staff. They reviewed care records, medicines records, recruitment files and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found improvements in medicines safety, cleanliness, staffing, activities and quality checks. People received medicines on time, were treated with kindness and had choices about their care and daily lives.
The previous rating was Requires Improvement, published in December 2018, with a breach of Regulation 17. The home had made enough improvement by this inspection and was no longer in breach. Inspectors still found some care plans and records that needed updating.
Safer medicines
The home had introduced an electronic medicines system and inspectors found that people received medicines on time and as prescribed.
“We found medicines systems and processes were safe.” from the report
Kind and respectful staff
Staff knew people well, treated them with patience and respected their privacy, dignity, beliefs and choices.
“Staff were kind, caring and compassionate.” from the report
Personalised activities
People could choose from home-based and community activities based on their interests and wishes. The home also supported people to maintain relationships with family and friends.
“The activity timetable included many community-based activities such as going to the bookies, out for meals and walks.” from the report
Improved management
Quality checks had improved since the previous inspection. The manager sought feedback and had identified further improvements to make.
“Improvements had been made to quality assurance systems and processes which enabled the registered manager to identify areas for improvement.” from the report
Some records were incomplete
needs fixingOne person's catheter care plan was missing, and other plans had not been updated after a change in need. The manager acted promptly, but the report says further auditing and updates were still under way.
“We identified one person's catheter care plan was missing and their PEEP and mobility care plan had not been updated following a recent change in need.” from the report
Aggression care plans needed clearer instructions
needs fixingInspectors said some care plans for managing aggression did not yet give staff clear enough instructions. Nurses were working on making these plans more personal and detailed.
“Improvements were required to care plans for managing aggression to provide clear instructions for staff to follow.” from the report
- 01How do you now check that electronic care plans are complete and updated when someone's needs change?
- 02What clear instructions are in place for staff supporting people whose behaviour may present risks?
- 03How are medicines, including as-required medicines, monitored to make sure they are given safely and only when needed?
- 04Which activities and community outings could be provided for my relative, based on their interests and wishes?
- 05How will you involve my relative and our family in reviewing their care plan?
This was an unannounced planned inspection covering all five CQC questions; inspectors also made telephone calls to relatives on 25 and 26 November 2019. This explanation was written from the published report of 24 December 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 Matthews Limited - The Avenue
5 rated inspections over 6 years: the service has held its Good rating throughout.
- January 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Matthews Limited - The Avenue →
- December 2019Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Matthews Limited - The Avenue →
- December 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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At least 100 live-in carers within about an hour of West Northamptonshire
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 £1,280 a week. 87 can care for a couple. 12 years' experience on average.
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