CQC report explained · a nursing home
What the CQC found at St Matthews Unit
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, safeguarding and safety checks had improved. However, wound care guidance and pain management were not always adequate, and instructions for as-needed medicines were not always available.
- Effective?
- Requires improvement
- Training and joint working with health professionals had improved. DoLS records were incomplete, around half of the people were awaiting medicine reviews, and the environment did not always support orientation or sensory needs.
- Caring?
- Good
- Inspectors observed kind and respectful care. People were involved in decisions, supported to make choices and encouraged to maintain independence.
- Responsive?
- Requires improvement
- Care plans were not always personalised or fully developed. Relatives raised concerns about noise, missed care reviews and a lack of stimulation and activities.
- Well-led?
- Requires improvement
- Audits, action plans and management oversight had improved. However, there had been recent management changes, no registered manager was in post during the visit, and improvements were not yet fully embedded.
What inspectors found, September 2023
St Matthews Unit is rated Requires Improvement; inspectors found kind care and progress, but medicines, wound care and personalised planning still needed work.
Inspectors visited without notice on 15 and 16 June 2023. They spoke with people, relatives and staff, and reviewed care records, medicine records, staff files and management records. They also checked infection prevention and control.
The home had improved since its previous Inadequate rating. Staff were caring, there were enough staff to meet people's needs, and training, safeguarding records and management oversight had improved. However, wound and pain management, instructions for as-needed medicines, some care plans and access to activities were not yet reliable enough.
The overall rating changed from Inadequate to Requires Improvement. Safe, Effective, Responsive and Well-led were rated Requires Improvement. Caring was rated Good. The home had been in Special Measures, but inspectors found enough improvement for it to leave Special Measures.
Kind and respectful care
Inspectors saw genuine kindness between staff and people. People and relatives generally said staff treated them with respect.
“The care we observed during the inspection between people and staff appeared to be given with genuine kindness.” from the report
Improved safety oversight
The home had improved its safeguarding reporting, incident reviews and safety checks. Fire, water and evacuation records were up to date.
“At this inspection we found all maintenance checks, including those for fire and water were up to date and documented in detailed comprehensive records, to ensure the environment was safe.” from the report
Enough staff
Staffing levels matched the home's dependency assessment during the inspection. Relatives and staff said there were enough staff to meet people's needs safely.
“There were enough staff to meet the needs of people safely.” from the report
Improved management systems
The provider had introduced stronger audits, action plans, daily meetings and a new management structure. Staff and relatives reported better communication.
“The provider had developed more robust systems of auditing and monitoring which was undertaken internally and by the provider's quality team.” from the report
Wound pain and restraint
seriousA person was regularly physically restrained while a wound was redressed. Inspectors found there was no evidence that pain medicine had been considered beforehand, although action was taken during the inspection.
“Not having appropriate guidance for staff placed people at risk of harm.” from the report
As-needed medicines
seriousInstructions did not always tell staff why and when as-needed medicines should be given. The manager said protocols were reviewed and put in place during the inspection.
“Where people required medicine on an as and when basis (known as PRN), the provider had failed to ensure there was information available to guide staff how and when to support people to take these” from the report
Care plans not fully up to date
needs fixingSome care plans did not give enough guidance about current needs, wounds or personal preferences. Staff were still reviewing and updating them.
“Inspectors found some care plans were not up to date.” from the report
Activities and noise
needs fixingSome relatives felt there was not enough stimulation, and some said the home was too noisy for their relative. The weekly activity timetable did not cover everyone.
“However, relatives we spoke with felt there was a lack of stimulation and activity for people.” from the report
Medicine reviews delayed
needs fixingStaff said about half of the people were still waiting for medicine reviews. This had been escalated and the home was contacting the local GP surgery weekly.
“Staff told us approximately half of all the people living at the service were still awaiting medicine reviews which was causing staff concern.” from the report
No registered manager at the visit
needs fixingThere was no registered manager in post during the inspection. A new manager had been recruited and was due to apply for registration.
“At the time of our inspection there was not a registered manager in post at the service.” from the report
- 01What written guidance is now in place for wound care and managing pain before dressings?
- 02How do you check that as-needed medicines have clear instructions about why and when they should be given?
- 03How many people are still waiting for medicine reviews, and what action is being taken to complete them?
- 04How will you update my relative's care plan to include their preferences, communication needs and sensory needs?
- 05What activities and outings are available for people who need one-to-one support, and how do you manage noise levels?
This was an unannounced follow-up inspection after the previous Inadequate rating, with infection prevention and control also checked; inspectors rated all five key questions. This explanation was written from the published report of 2 September 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, July 2022
Inadequate and in special measures; inspectors found people at risk from unsafe practices, weak oversight and incomplete action on earlier concerns.
Inspectors made an unannounced visit on 11 May 2022. They spoke with four people and nine staff, and checked care records, medicines records, staff files and management records. They also looked at infection prevention and control.
The home was not safe. People were at risk from fire, scalding, legionella and inappropriate physical interventions. Records were incomplete, some staff training was out of date, and checks had not always led to action. Medicines, staffing levels, recruitment and infection control were areas inspectors found satisfactory.
The overall rating was Inadequate. Effective, caring and responsive were rated Requires Improvement, while Safe and Well-led were rated Inadequate. The home had been rated Requires Improvement at the previous inspection, and remained in breach of regulations despite its action plan.
Medicines
Medicines were given as prescribed and records were kept up to date. Staff had been trained and assessed in medicines management.
“Medicines were managed safely. People's medicine administration records (MAR) were appropriately signed to evidence medicines were given as prescribed.” from the report
Staffing
Inspectors found enough staff to meet people's needs. Permanent staff recruitment records included references and DBS checks completed before staff started.
“There were enough staff to meet people's needs. People told us they felt staffing levels were adequate and staff rota's confirmed this.” from the report
Health support
Staff worked with health professionals and arranged appointments when people needed them. Care plans recorded health needs and professional advice was followed.
“Staff worked with other professionals, people were referred to appropriate health professionals such as, speech and language therapists when required.” from the report
Infection control
Inspectors were assured that the home used PPE safely, followed infection control arrangements and could prevent or manage infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Physical interventions
seriousRecords often did not state the type or duration of physical intervention, or identify all staff involved. Some incidents were not recorded or reviewed, so inspectors could not be assured that interventions were safe.
“This meant there was no evidence of whether or not the techniques used were appropriate or safe.” from the report
Fire and water risks
seriousFire risks had not been properly assessed or dealt with. Hot water temperatures created risks of scalding and legionella, and records showed water storage had failed to reach the recommended temperature for four weeks.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Training
needs fixingSome staff did not have up-to-date training in safeguarding, manual handling, communication, food and fluids. Agency staff did not always have recorded induction or physical intervention training.
“Staff had not always completed the necessary training to understand and meet people's needs.” from the report
Privacy and involvement
needs fixingSome people could not lock their bedroom doors when away from their rooms. Inspectors also received mixed feedback about whether people were listened to and involved in decisions.
“Some people were unable to lock their bedroom door when they were out.” from the report
Management oversight
seriousAudits and quality systems did not identify or reduce known risks. Records could not always identify agency staff, and the improvement plan did not give clear actions or deadlines.
“Systems and processes had not been effective to assess, monitor and improve the quality and safety of the service.” from the report
- 01What has been done to fix the fire door, fire alarm, fire drill and blocked fire exit concerns?
- 02How are hot water temperatures, legionella risks and portable heaters now checked and recorded?
- 03How are physical interventions recorded, reviewed and followed by debriefs with people and staff?
- 04Which staff and agency workers have now completed safeguarding, manual handling, communication, food and fluids training?
- 05How are complaints, bedroom privacy concerns and people's feedback about activities now recorded and acted on?
This was an unannounced inspection of the care and nursing provided and the premises, covering all five key questions and infection prevention and control. This explanation was written from the published report of 29 July 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 Matthews Unit
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- April 2021Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2017Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedWell-led: Inspected but not rated
- May 2017Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- May 2013
Report published without a new overall rating.
- November 2012
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 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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