CQC report explained · a nursing home
What the CQC found at St Peters Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2020
Rated Good overall, but inspectors found weaknesses in quality monitoring, staff training and leadership.
This was an unannounced focused inspection on 11 November 2020. Inspectors looked at whether the home was safe and well-led, including infection control. They spoke with people, relatives and staff, and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe. People and relatives said they felt safe. Medicines were given as prescribed, recruitment checks were in place and staff used personal protective equipment appropriately. However, staffing levels received mixed feedback, some practical fire training was incomplete and not all infection control training was up to date.
The home was rated Requires Improvement for Well-led. Monitoring systems did not always identify missing health records or check that safeguarding concerns had been dealt with properly. Staff training, supervision and competency records were also not consistently up to date.
The overall rating remained Good because other areas were not inspected during this focused visit and their previous ratings were used. The previous overall rating was also Good, published on 30 October 2019.
People felt safe
People and relatives said they felt safe in the home. Staff knew how to raise safeguarding concerns.
“Relatives told us they felt people living in the home were safe.” from the report
Medicines
People received their medicines as prescribed. Care plans gave staff clear instructions about how each person preferred to be supported.
“People received their medicines as prescribed and staff had clear information about how people liked to be supported.” from the report
Safe recruitment
The home had completed the relevant recruitment checks and documentation.
“Staff recruitment processes were safe, with all relevant documentation and checks in place.” from the report
Family involvement
Relatives said they were involved in decisions about people's care and spoke positively about the home.
“Relatives told us they felt involved in people's care.” from the report
Infection control
The home was clean and staff were seen regularly cleaning and sanitising surfaces. Inspectors were assured about the use of protective equipment and outbreak arrangements.
“Staff were seen cleaning and sanitising surfaces on a regular basis throughout the inspection.” from the report
Incomplete health monitoring
needs fixingSome care records did not contain up-to-date health monitoring information, such as recent weights. This created a risk that changes in people's health could be missed.
“People's care records did not always contain up to date monitoring information relating to their health.” from the report
Safeguarding follow-up
seriousThe home did not always check staff practice promptly after concerns were raised. For example, night checks had not been completed when concerns about night care were reported.
“Where safeguarding concerns had been raised the provider had not always acted promptly to ensure people were being kept safe.” from the report
Staff training and supervision
needs fixingTraining was not up to date for all staff and agency workers did not always have training suited to people's needs. Supervision and competency records were also incomplete.
“Staff training was not up to date and staff had not always received training tailored to people's individual support needs.” from the report
Staffing levels
needs fixingPeople gave mixed feedback about whether there were enough staff on shift. The home used agency workers alongside permanent staff.
“We received mixed feedback regarding staffing levels in the service.” from the report
Fire and infection training
needs fixingNot all staff had completed practical fire training or fire drills, and not all staff had updated infection prevention and control training. The provider said a fire drill was completed after the inspection.
“Staff completed online fire safety training, however not all staff had completed practical training or fire drills.” from the report
- 01What checks are now used to make sure people's weights and other health records are kept up to date?
- 02How do you investigate and follow up safeguarding concerns, including concerns about night care?
- 03Which staff and agency workers have completed dementia care and other training tailored to residents' needs?
- 04How do you check that staff supervision and competency assessments are current?
- 05What is the current staffing arrangement, and how do you respond when a staff member is absent?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 25 December 2020 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, November 2019
Rated Good; inspectors found major improvements and kind, safe care, but some privacy and care-planning arrangements still needed attention.
This was an unannounced inspection of the whole home. Inspectors spoke with people, relatives, staff and a health professional. They observed care and reviewed care plans, staff recruitment records and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines management, improved care records and better systems for checking the quality of care.
People were treated with kindness and respect. Staff knew people's needs and supported their independence, health, activities and relationships. Food, healthcare support, complaints handling and end of life care were also found to be good.
The previous inspection in September 2018 found multiple breaches and rated the home Requires improvement. At this inspection, the provider had made enough improvements and was no longer in breach of regulations.
Improved staffing
The home recruited permanent staff and significantly reduced its use of agency staff. Inspectors found enough staff on the inspection day and saw that staff had time to spend with people.
“There were enough staff to meet people's needs during our inspection.” from the report
Safer medicines and risk management
Risk assessments had been made more complete and medicines were ordered, stored, given and recorded through an improved system.
“There was a robust process in place for the ordering, storing, dispensing, recording and disposal of medicines.” from the report
Kind and respectful care
Staff knew people well and supported their choices, dignity and independence. Families also described the care as kind and respectful.
“Staff knew people well, their personalities and preferences and treated them with kindness, gentleness and warmth.” from the report
Person-centred activities
A new activities coordinator was developing activities based on individual interests and abilities, rather than relying only on group activities.
“They were creating individualised ways of giving people purpose, interest, stimulation and enjoyment.” from the report
Stronger leadership
A new manager had introduced clearer responsibilities, regular checks and an action plan for continued improvement.
“Significant improvements had been made to the management and quality of care for people and for staff.” from the report
Privacy in shared rooms
needs fixingSome bedrooms were shared with only a curtain providing separation. Inspectors found very little privacy and the home did not initially have relevant authorisation showing consent for all shared-room arrangements.
“Some people shared a room with another person. We saw that the rooms were divided by a curtain, with very little privacy being available.” from the report
Care-plan involvement
needs fixingPeople and relatives were not always shown care plans or asked to sign that they agreed with them. The manager introduced steps to review plans with them and provide copies for signing.
“People and their relatives were not always fully involved in their care plan arrangements.” from the report
Untidy storage room
minorOne room used for storing hoists and used slings had been missed from the cleaning audit and was unclean and untidy. The home acted immediately to clean it and change the storage system.
“The room was unclean and untidy.” from the report
Limited community links
minorThe home was not making as much use as it could of local community facilities and resources. Developing these links was part of its action plan.
“The service did not engage as much as they could with the local community and all that it offered, despite being near a town.” from the report
- 01How have you kept staffing levels stable, and how much agency staff do you use now?
- 02How do you record consent and protect privacy for people who share bedrooms?
- 03Are residents and relatives shown the care plan and asked to sign their agreement to it?
- 04What cleaning checks are now in place for equipment storage areas, including hoists and slings?
- 05What progress has been made in developing activities and links with the local community?
This was an unannounced inspection of all five key questions, following the previous Requires improvement rating and multiple regulatory breaches. This explanation was written from the published report of 1 November 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 Peters Court
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- December 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2019
Registered with the Care Quality Commission on 18 June 2019.
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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