CQC report explained · a residential care home
What the CQC found at St Peter's Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Risks were assessed and monitored, and staff knew how to respond, but some risk assessments did not contain full instructions about what to do if risks occurred. Inspectors said there was limited assurance about safety.
- Effective?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This key question was not assessed during this focused inspection. Its previous rating was carried forward into the overall rating.
- Well-led?
- Good
- Inspectors found stronger leadership, regular audits, clearer staff roles and an open culture. The manager had an action plan and acted when audits found shortfalls.
What inspectors found, December 2021
Rated Good overall, but Safe Requires Improvement; the home has left special measures after major improvements.
This was an unannounced, focused inspection on 3 November 2021. Inspectors checked Safe and Well-led, spoke with five people, three relatives and eight staff, and reviewed care, medicines, recruitment and management records.
The home had improved since its previous Inadequate rating. Inspectors found enough staff, safer medicine systems, safer recruitment, better infection control and appropriate action when incidents or safeguarding concerns occurred. However, some risk assessments did not explain clearly enough what staff should do if a risk happened.
The home was rated Good overall. Safe was rated Requires Improvement and Well-led was rated Good. The other key question ratings were carried forward from the previous comprehensive inspection, so they were not assessed during this visit.
Improved leadership
Inspectors found that management had improved significantly. Staff and people had confidence in the manager, and audits and action plans were being used to improve the service.
“Management of the service had improved significantly.” from the report
Staffing and training
There were enough staff during the inspection, call bells were answered promptly and staff had training for people's specific health needs.
“There was enough staff on duty throughout the day and night to make sure people received the care and support they needed in a timely manner.” from the report
Medicines
Medicines were stored safely and people received them consistently. Audits and guidance for medicines given when needed had been improved.
“Medicines were managed and stored safely at the right temperature.” from the report
Learning from incidents
The home reviewed accidents and falls and took action to reduce the chance of them happening again. Inspectors noted that falls had reduced significantly.
“There were systems in place to monitor and analyse accidents and incidents to prevent them happening again.” from the report
Risk instructions were incomplete
needs fixingSome risk assessments did not say fully what staff should do if a risk happened. This included risks linked to diabetes and pressure sores, although the manager addressed the shortfalls during the inspection.
“However, some risk assessments did not include full guidance for staff on what action to take if the risks occurred.” from the report
Formal feedback had not started
minorThe manager had not yet sent formal surveys to people, relatives and staff because they had only been at the home for a few months. Surveys were planned for the near future.
“The registered manager had not yet sent out formal surveys to people, relatives and staff as they had only been at the service for a few months.” from the report
- 01How have you kept the risk assessments up to date since the inspection, particularly for diabetes and pressure sores?
- 02What written instructions do staff now have about what to do if a person's health risk occurs?
- 03How do you check that the improvements found at this inspection have been sustained?
- 04Have you now sent formal surveys to people, relatives and staff, and what did the feedback show?
- 05How are medicines audits checked after an error or missed dose is found?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 8 December 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, June 2021
Rated Inadequate and placed in special measures; inspectors found serious risks to safety, medicines, infection control and leadership.
This was an unannounced focused inspection on 13 May 2021. Two inspectors spoke with people, relatives, staff and a health professional. They reviewed care records, medicine records, recruitment files and management records.
The inspectors found people were at risk of avoidable harm. Risks from falls, poor fluid intake, catheters, diabetes, fire safety, medicines and infection were not managed well. Staff numbers were enough, but staff did not have the training and checks needed to support people safely.
Leadership was rated Inadequate. The provider did not identify or learn from incidents, did not monitor risks properly and did not involve people, relatives or staff effectively. The overall rating fell from Good at the previous inspection, published in January 2020, to Inadequate.
Enough staff on duty
The inspectors found there were enough staff to meet people's needs. However, staff did not have the required training and competency checks.
“Although there were enough staff to meet people's needs staff had not been given the training to support people well.” from the report
Safe admissions
The inspectors were assured that admissions to the home were being made safely.
“We were assured that the provider was admitting people safely to the service.” from the report
People were at risk of harm
seriousSafeguarding procedures were not followed after a serious injury, and concerns were not reported to the appropriate outside agencies. Risks from falls and people's health needs were also poorly managed.
“People were not protected from the risk of avoidable harm.” from the report
Medicines were not safely managed
seriousMedicine records and storage were not reliable. Temperatures were too high, unwanted medicines were left in boxes, and staff lacked guidance for medicines given when needed.
“Medicines were not always managed or stored safely.” from the report
Infection control gaps
seriousThere was no written plan for managing another outbreak. Some staff did not wear masks, high-touch cleaning was not added to schedules, and entry checks were not carried out consistently.
“We were not assured that the provider was protecting people from the risk of infection.” from the report
Weak leadership and oversight
seriousThe provider did not identify serious problems found by inspectors, including falls, medicine and fire risks. There was little evidence of learning, auditing or effective support for staff.
“There was a lack of leadership and oversight at the service resulting in poor outcomes for people.” from the report
- 01What action has been taken to assess and reduce the risks of falls, including for people who previously had no falls risk assessment?
- 02How are medicine temperatures, discontinued medicines, unwanted medicines and creams now checked and recorded?
- 03What written plan is now in place for managing a COVID-19 or other infection outbreak?
- 04Which staff have completed and passed competency checks for fire safety, moving and handling, catheter care and diabetes support?
- 05How are incidents, including falls and safeguarding concerns, now reported, reviewed and used to prevent them happening again?
This was a focused inspection of Safe and Well-led, including infection control under Safe; the other key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 24 June 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.
Every inspection of St Peter's Care Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- December 2021Goodcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- January 2020Goodstayed GoodSafe: Requires improvementWell-led: Good
- May 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- March 2013
Registered with the Care Quality Commission on 11 March 2013.
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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