CQC report explained · a residential care home
What the CQC found at St Nicholas House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors were assured that infection risks were being managed through testing, protective equipment, hygiene, visiting arrangements and outbreak procedures. One risk assessment did not fully cover all risks, and the provider took swift action to address this.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, April 2021
Inspected but not rated; inspectors found strong infection-control arrangements, but one risk assessment did not fully cover all risks.
This was an unannounced, targeted inspection of infection prevention and control. The visit took place on 19 January 2021, with inspection activity continuing until 22 January 2021.
Inspectors were assured about testing, admissions, protective equipment, hygiene, visiting arrangements and managing outbreaks. Staff and residents were tested in line with government guidance, and the building had accessible hand-washing areas and protective equipment stations.
Inspectors found that one risk assessment did not show that all risks had been fully considered for a person using a communal toilet. The provider acted quickly to expand the assessment and change practice.
The service was inspected but not rated. This report does not give a full quality rating for the care home.
Regular COVID-19 testing
The home tested residents and staff regularly in line with government guidance. This helped identify positive cases promptly.
“The service completed regular COVID-19 testing for people who use the service and staff in line with current government guidance.” from the report
Protective equipment and hand washing
Protective equipment stations and hand-washing areas were made accessible throughout the home. Inspectors said this reduced the risk of infection spreading.
“The service had adapted areas of the building to ensure that Personal Protective Equipment (PPE) stations and hand wash areas were accessible at all times.” from the report
Monitoring people's health
People's wellbeing was checked daily, including twice-daily temperature checks and action when coronavirus symptoms developed.
“The well being of all individuals was closely monitored on a daily basis.” from the report
Clear information about infection control
Signs explained coronavirus symptoms and how to put on and remove protective equipment safely.
“Clear signage was on display throughout the service in relation to the signs and symptoms of COVID-19 and how to don and doff PPE appropriately.” from the report
Risk assessment was incomplete
needs fixingOne risk assessment did not show that all risks had been considered for a person using a communal toilet. The provider acted quickly to expand the assessment and change practice.
“This document did not evidence that all risks had been fully assessed for this individual or others.” from the report
- 01What changes were made to the risk assessment for using the communal toilet?
- 02How do staff make sure all relevant risks are now recorded and reviewed?
- 03How often are residents and staff tested for COVID-19?
- 04How are visitors admitted safely and protected from infection?
- 05How does the home manage a suspected or confirmed infection outbreak?
This was a targeted inspection of infection prevention and control, reported under Safe; it did not assess Effective, Caring, Responsive or Well-led and gave no overall quality rating. This explanation was written from the published report of 28 April 2021 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, March 2019
Rated Good overall; inspectors found kind, personalised care, but safety checks needed improvement.
This was an unannounced inspection on 24 January 2019. One inspector and an Expert by Experience spoke with five people, four relatives and nine staff. They observed care and checked care plans, medicines records, recruitment files, training and quality checks.
People and relatives spoke positively about the care. Staff knew people well, treated them with dignity, supported independence and offered activities. People's health, food and medicines were generally well managed.
The main weakness was safety. Inspectors found several environmental risks, including unsafe equipment, a loose wardrobe and a broken window restrictor. End of life planning also needed more detail. The home was rated Good overall, but Safe was rated Requires Improvement and the other four areas were rated Good.
Kind and respectful care
People and relatives consistently described staff as caring. Staff knew people as individuals and communicated in ways that supported their understanding.
“People and their relatives consistently told us that staff were kind and caring.” from the report
Choice and independence
People could choose where to spend time, what to eat and whether to join activities. Staff supported people to do things for themselves.
“People were encouraged to be independent. Care plans identified what a person could do for themselves and what they needed help with.” from the report
Activities and community links
People had access to daily activities, exercise classes and trips into the local community. Activities were linked to people's interests and wellbeing.
“People could take part in activities that interested them and the planned activities were on display.” from the report
Health and medicines
People were supported to access health professionals and received their medicines when needed. Staff had medicines training and competency checks.
“Medicines were managed safely. There were systems for ordering, administering and monitoring medicines.” from the report
Positive management
The management team was visible and approachable. Staff said their views were heard, and audits and development plans were used to support improvement.
“The culture of the service was caring and staff were passionate and motivated about supporting people.” from the report
Environmental safety risks
seriousInspectors found several hazards that had not been identified. The walking frame was still being used a week after the inspection without its worn parts being replaced.
“Some environmental risks in the service had not been identified and systems required improvement to ensure the environment was consistently safe.” from the report
Staffing concerns at busy times
needs fixingFeedback from some relatives and a survey suggested staffing could be thin at evenings and weekends, with some people waiting for help. Inspectors saw staff responding quickly during the visit.
“Recent feedback from a survey that had been sent to relatives showed that out of the 13 comments that had been received, five mentioned that there were not enough staff.” from the report
End of life planning
needs fixingThe care provided at the end of life was described positively, but plans did not always include people's preferences, cultural requirements or wishes after death.
“End of life care planning could be further developed to include people's preferences, cultural requirements and their wishes after they died.” from the report
Kitchen flooring
minorThe kitchen floor was heavily stained and some areas were difficult to clean. The home nevertheless had a five-star food safety rating from the Food Standards Agency.
“The flooring in the kitchen was heavily stained and some areas of the kitchen floor were difficult to clean to prevent any build-up of bacteria.” from the report
- 01Have the unsafe walking frame, wobbly wardrobe and broken bathroom window restrictor now been repaired or replaced?
- 02How do you make sure environmental safety checks identify hazards before someone could be harmed?
- 03How many staff are available in the evenings and at weekends, and how do you prevent people waiting for help?
- 04How will end of life plans record a person's preferences, cultural requirements and wishes after death?
- 05What improvements have been made to the stained kitchen flooring and the areas that were difficult to clean?
This was a planned, unannounced inspection of the care home and its accommodation, care and five rated areas, using observations, discussions and records. This explanation was written from the published report of 7 March 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 Nicholas House
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- March 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 25 April 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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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