CQC report explained · a residential care home
What the CQC found at St Peter's House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Requires Improvement; inspectors found unmanaged risks, medicines and staffing shortfalls, and weak oversight at St Peter's House.
This was an unannounced focused inspection on 13 and 27 July 2023. Inspectors spoke with people, relatives and staff, reviewed care and medicine records, and checked how the home was managed.
They found that risks were not always properly assessed or managed. Medicines were not always given or recorded safely. There were concerns about delays in answering call bells, people’s basic care needs, food and fluid records, and referrals after falls.
The home’s systems for checking quality were not effective enough to find and fix these problems. The overall rating changed from Good at the previous inspection, published on 24 May 2022, to Requires Improvement. Only Safe and Well-led were inspected in this visit. The other ratings carried over from the previous inspection.
Safeguarding knowledge
Staff had training and understood how to identify and report safeguarding concerns.
“Staff had been trained to safeguard people from abuse and understood when and how to report safeguarding concerns to the appropriate authority.” from the report
Safe recruitment
The home completed references and criminal record checks before staff were employed.
“People were supported by staff who had been recruited safely.” from the report
Infection control
Inspectors were assured about the home’s infection prevention measures, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Open response
The provider accepted the findings and acted during and after the inspection.
“The provider demonstrated an open and transparent approach and understood their responsibilities under the duty of candour.” from the report
Unmanaged risks
seriousRisk assessments did not contain enough guidance for staff. Inspectors also found an unsecured wardrobe and gaps in food, fluid and oral care records.
“Risks had not been sufficiently assessed. Risk assessments were missing detailed guidance for staff on how to reduce risks.” from the report
Medicine safety
seriousSome medicines were unclear, unsecured or not recorded consistently. There were also concerns about missed medicines, creams and medicines given when people refused them.
“Although we found no evidence that people had been harmed, the safe management of medicines was not always effective.” from the report
Weak quality checks
seriousAudits and governance systems did not identify or resolve important problems. Records were not always complete or accurate.
“The provider had failed to assess, monitor, and improve the service.” from the report
Management culture
needs fixingMany people, relatives and staff described a difficult atmosphere and ineffective management arrangements. The provider said it took immediate action to review these arrangements.
“We received overwhelmingly strong feedback that the management arrangements at the home were not effective or conducive to a professional working relationship.” from the report
- 01What specific changes have been made to risk assessments, especially for people at risk of falls or taking anticoagulant medicines?
- 02How are missed, refused and as-required medicines now recorded and followed up?
- 03How many staff are deployed on each floor and shift, and how are call bell response times checked?
- 04What has changed in the quality audits, and how do you make sure actions are completed?
- 05What is the current management arrangement following the registered manager leaving shortly after the inspection?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 7 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, May 2022
Rated Good across all five areas; inspectors found kind, safe care, with minor gaps in recruitment records and dining arrangements.
This was an unannounced inspection on 5 May 2022. Inspectors spoke with people, relatives, staff and a visiting health professional. They observed care and checked care plans, medicines, staffing, recruitment, training, incidents and management records.
The inspection was prompted partly by concerns about staffing, premises safety, staff care, management and infection control. Inspectors found no evidence that people were at risk of harm from these concerns. They found safe medicine management, suitable staffing, skilled care and good infection control.
People and relatives described staff as kind, respectful and responsive. The home supported choice, independence, activities, healthcare and end of life care. All five areas were rated Good. This was the first inspection under the current provider. The previous provider had been rated Outstanding overall in 2017.
Safe medicines
Medicines were administered, stored and recorded safely. Staff received training and audits were used to identify errors.
“People received their medicines as prescribed; medicines were safely managed, and staff ensured they followed infection prevention guidance and good practise.” from the report
Skilled staff
Staff received role-appropriate training, supervision and competency checks. People and relatives felt staff had the skills needed to provide good care.
“Staff had received the training appropriate to their roles and had ongoing support to help them maintain and improve their skills to fulfil their responsibilities.” from the report
Kind and respectful care
People were treated with dignity and compassion. Staff supported privacy, choice and independence.
“People said staff were caring and knew their needs and preferences well. Staff gave people privacy, treated them with dignity and respect, and helped promote people's independence.” from the report
Personalised support
Staff knew people's preferences and changed care plans when needs changed. People were supported to communicate, take part in activities and maintain relationships.
“Staff knew how to respond to the finer points of people's lives based on individual preferences.” from the report
Open management
The manager used audits, reviews and staff checks to monitor the home. Staff described a supportive culture focused on putting people first.
“Monitoring and oversight of the service was effective in identifying and driving improvements.” from the report
Employment history check
needs fixingOne staff record had a six-year gap in employment history that had not been recorded as explored at interview. The manager checked the reason immediately, and other recruitment checks were complete.
“However, we found that in one staff's record there was a gap of six years which had not been recorded as being explored at interview.” from the report
Dining items
minorNapkins and condiments were not always available. The manager said the dining experience was being reviewed and staff would be reminded.
“However, our observations and several relatives told us, that napkins and condiments were not always provided.” from the report
Building work ongoing
minorThe home was being refurbished, but work was still needed on the heating system, passenger lift and a flat roof leak.
“Further work was in progress including addressing issues with the heating system, passenger lift and flat roof leak.” from the report
- 01How do you now make sure every applicant has a complete employment history, including any gaps?
- 02What has changed since the inspection to make sure napkins and condiments are available at mealtimes?
- 03Have the heating system, passenger lift and flat roof leak now been dealt with?
- 04How will you involve residents, relatives and staff now that formal meetings are being reintroduced?
- 05How do you support each person's oral healthcare and access to dental services?
This was an unannounced inspection covering all five key questions, including infection control, and it also included a separate thematic probe about oral healthcare. This explanation was written from the published report of 24 May 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 Peter's House
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Gooddown from OutstandingSafe: GoodWell-led: Good
- November 2017Outstandingup from GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- December 2020
Registered with the Care Quality Commission on 11 December 2020.
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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23 live-in carers within about an hour of Suffolk
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 £1,020 to £1,260 a week. 17 can care for a couple. 7 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.