CQC report explained · a nursing home
What the CQC found at St Michaels Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
St Michaels Nursing Home was rated Good overall; inspectors found safe, kind care, but the home was not always responsive to activities, communication and daily choices.
This was an unannounced inspection. Two inspectors and an expert by experience spoke with people, relatives and staff. They also observed care and checked care plans, medicines records, complaints, staffing records and management checks.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found that risks, medicines, staffing, infection control and health care were generally managed well. People were treated with kindness, dignity and respect, and staff knew their care needs.
Responsive was rated Requires Improvement. Activities did not always match people's interests or communication needs. Inspectors also saw delays in responding to some requests and a meal arrangement that did not take account of one person's choice. Improvements were under way, but had not yet been shown to be fully established.
Safety and risk management
Inspectors found that risks relating to people's health, the environment and equipment were assessed and managed. Incidents were monitored to help improve care and prevent recurrence.
“Overall, risks to people's safety were effectively assessed and managed.” from the report
Medicines
Medicines were ordered, stored, given, recorded and disposed of safely. Inspectors observed appropriate checks when staff administered medicines.
“We found safe arrangements for the ordering, receipt, storage, administration, recording and disposal of people's medicines when needed.” from the report
Kind and respectful care
Staff were seen engaging with people in a kind way. People and relatives gave positive feedback about staff's caring approach.
“During this inspection, we observed staff engaging with people in a kind, caring manner.” from the report
Management oversight
Managers had systems to monitor the quality and safety of care. They could show several improvements that had been made or were under way.
“Overall, the provider had established effective arrangements for governance and service oversight, to regularly check the quality and safety of people's care and inform service improvements.” from the report
Activities and daily choices
needs fixingPeople did not always have enough opportunities to take part in activities they enjoyed or understood. Improvement actions had been identified, but they were not yet fully established or sustained.
“arrangements and opportunities for people to participate in social activities they enjoyed or in a way they understood, did not always meet with their known choices, needs and preferences.” from the report
Timely responses and meals
needs fixingInspectors saw two occasions when staff did not respond promptly to verbal requests. One person's lunch was served only two hours after a late breakfast and was not adjusted to their choice.
“During this inspection, we observed two occasions when staff were present but did not respond in a timely manner, to people's verbal requests for assistance.” from the report
Short-term care planning
needs fixingOne person admitted for a few weeks of short-term care did not have the short-term care plan required by the home's policy. Inspectors said this could increase the risk of inconsistent or ineffective care, although other information was available and corrective work had started.
“one person recently admitted to the service for a few weeks short term care, did not have a short-term care plan devised by the service following their admission, as per the provider's policy.” from the report
- 01What activities are now available, and how do you make sure they match each person's interests, abilities and communication needs?
- 02How will staff support a person who prefers British Sign Language, and what training has been completed since the inspection?
- 03How do you make sure people receiving short-term care have a care plan in place immediately after admission?
- 04How do you monitor response times to requests and make sure meal times allow for each person's choices and needs?
- 05What happened to the complaint that was still in progress at the inspection, and how was the outcome communicated?
This was an unannounced first comprehensive inspection of the newly registered service and covered all five key questions. This explanation was written from the published report of 6 July 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
Inspected but not rated; inspectors found infection controls largely in place, but building improvements were not yet complete.
This was an unannounced, targeted inspection after concerns about infection prevention and control. Inspectors visited on 17 January 2022 and reviewed some management records using technology on 18 January 2022. They also asked about staffing pressures.
The home had introduced new infection control procedures after its registration and change of ownership in December 2021. Inspectors were assured about visiting, testing, isolation, personal protective equipment, admissions, social distancing and managing outbreaks.
Cleaning schedules, bedding and staff guidance had been revised. A wider programme to repair and refurbish the building was under way, but the inspectors could not yet confirm that all environmental improvements were complete. They also saw enough staff on duty to provide people's care.
The home was inspected but not rated. This means the visit focused on infection control and staffing rather than giving an overall judgement on the quality of care.
Infection control procedures
The home had introduced comprehensive procedures for preventing and controlling infection, including arrangements for admissions, visiting, testing and isolation.
“The provider had introduced revised comprehensive arrangements and related procedures, in line with nationally recognised guidance and the law, for the prevention and control of infection at the service.” from the report
Staffing on inspection days
The inspectors saw enough staff on duty to provide people's care during the inspection.
“At this inspection we saw there were enough staff on duty, to provide people's care.” from the report
Building improvements unfinished
needs fixingCleaning schedules and environmental improvements had started, but the planned repair, refurbishment and renewal work was not yet fully complete.
“However, this was not yet demonstrated as fully completed.” from the report
- 01Which parts of the planned repair, refurbishment and renewal work have now been completed, and what remains outstanding?
- 02How are cleaning schedules and cleaning of care equipment checked and monitored?
- 03How would the home manage an infection outbreak, including isolation and cohorting?
- 04How many staff are usually on duty, and have COVID-19-related staffing pressures affected care?
- 05How are visits, testing and personal protective equipment arrangements kept up to date?
This was a targeted inspection of infection prevention and control, with questions about staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 3 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 Michaels Nursing Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- July 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2021
Registered with the Care Quality Commission on 17 December 2021.
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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