CQC report explained · a residential care home
What the CQC found at St Saviours Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about visitors, admissions, PPE, testing, hygiene and managing outbreaks. They were only somewhat assured about shielding, social distancing and whether the infection control policy fully addressed higher risks.
- Effective?
- Good
- This question was not assessed in the targeted inspection.
- Caring?
- Good
- This question was not assessed in the targeted inspection.
- Responsive?
- Good
- This question was not assessed in the targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed in the targeted inspection.
What inspectors found, April 2021
St Saviours Care Home was inspected but not rated; inspectors found strong infection controls but gaps in some COVID-19 risk assessments.
This was an unannounced, targeted inspection on 23 March 2021. It looked at infection prevention and control during an ongoing COVID-19 outbreak.
Inspectors found good arrangements for visitors, personal protective equipment, testing, cleaning and monitoring people's health. People were supported to keep in touch with relatives by phone and video calls.
However, some people living with dementia who could not socially distance did not have individual risk assessments. Risk assessments for staff at higher risk from COVID-19 were also missing or did not always lead to action. The infection control policy did not fully consider people or staff who might be disproportionately affected by COVID-19.
The service was inspected but not rated. This means the inspection did not provide an overall quality rating or a rated judgement for safe care.
Visitor infection controls
Visitors were restricted during the outbreak, tested before entry and given suitable protective equipment.
“Visitors were protected from catching and spreading infection.” from the report
Protective equipment and testing
Staff had training in using protective equipment, and testing was carried out for staff and residents.
“The testing scheme for all staff and residents had been conducted – known as 'whole home testing'.” from the report
Clean environment
Inspectors found the home clean, with domestic staff assigned cleaning areas during their shifts.
“The home environment was clean.” from the report
Health monitoring
People were monitored for signs of physical deterioration, COVID-19 and other infections, with clinical support available when needed.
“People's health and wellbeing was monitored using nationally recognised physical deterioration and escalation tools.” from the report
Contact with relatives
People were supported and encouraged to keep in touch with relatives using phone and video calls.
“People were supported and encouraged to maintain contact with their relatives via phone calls and video calls.” from the report
Missing risk assessments for some people
seriousSome people living with dementia who could not socially distance did not have risk assessments to reduce the chance of infection spreading.
“People who lived with the dementia and were unable to socially distance did not have any risk assessments in place to reduce the risk of infection spread.” from the report
Higher-risk staff
seriousThe home had not completed risk assessments for staff in higher-risk groups, and action was not always taken to reduce the risks.
“The provider had not carried out risk assessments on staff belonging to a higher risk group and actions had not always been taken to reduce the risks.” from the report
Policy did not fully address unequal risks
seriousThe infection control policy was not fully up to date and did not always address the possible disproportionate impact of COVID-19 on some people and staff.
“Actions had not always been taken to consider and reduce the impact to people or staff who may have been disproportionately at risk of COVID-19 such as people from Black, Asian and Minority Ethnic (BAME) groups.” from the report
- 01Have individual risk assessments now been completed for people living with dementia who cannot socially distance?
- 02How are you assessing and reducing COVID-19 risks for staff who belong to higher-risk groups?
- 03What changes have been made to the infection prevention and control policy since this inspection?
- 04How do you identify and reduce disproportionate COVID-19 risks for people and staff from different ethnic backgrounds?
- 05How do you check that actions identified in risk assessments are actually completed?
This was an unannounced targeted inspection of infection prevention and control during a COVID-19 outbreak; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 10 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, September 2019
Rated Good overall, but well-led Requires Improvement because there was no registered manager and some quality checks and records needed improvement.
This was an unannounced inspection on 12 and 13 August 2019. Inspectors spoke with people living at the home, visitors and staff. They reviewed care records, medicine records, recruitment files and management documents.
People said they felt safe and were treated with kindness, dignity and respect. Inspectors found good support with food, drinks, healthcare, activities and end of life care. Staff knew people well and supported their choices and independence.
The main weakness was management oversight. There was no registered manager in post, and quality checks had not identified some issues with medicines records, fire drill records and communication information. The home was rated Good overall, with Safe, Effective, Caring and Responsive rated Good, but Well-led rated Requires Improvement.
Kind and respectful staff
People described staff as kind and friendly. Inspectors saw calm and caring interactions, with staff seeking permission before providing support.
“Staff spoke with people in a respectful manner and interactions were delivered in a smiling, calm, kind and caring manner.” from the report
Good support with food and drinks
People were regularly offered drinks and had varied meal choices. A healthcare professional praised the home's use of fortified food before prescribed supplements.
“People's nutrition and hydration needs were met. People were regularly offered drinks and staff took drinks trolleys around the home several times a day.” from the report
Activities and social life
Two activities co-ordinators supported activities every day, including a dementia café, music, dancing and games. People were also supported with faith activities.
“Two activities co-ordinators supported people seven days a week to participate in social activities.” from the report
Support at the end of life
End of life care plans were available where people and families wanted to discuss their wishes. Staff were described as committed to helping people feel loved and comforted.
“A healthcare professional said, "They particularly excel at end of life care. For this they should be commended.” from the report
Accessible and personalised environment
People could personalise their rooms, and communal areas were themed. The garden and courtyard were accessible and included sensory areas and raised beds.
“Outside areas were beautiful and well-tended. The garden and courtyard were fully accessible for people with sensory areas for relaxation, raised beds with flowers and vegetables, and hanging baskets strategically positioned to be seen from people's bedrooms.” from the report
No registered manager
needs fixingThere was no registered manager when inspectors visited. An application was later received but returned because it was incomplete.
“There was no registered manager in post. We were notified by the provider that the previously registered manager left their post on 28 February 2019” from the report
Medicines recording
needs fixingGuidance for some as-required medicines did not always explain when and how they should be given. Records for patches and creams also needed improvement.
“The recording of the application of these medicines could be improved by using topical medicine administration records and body maps.” from the report
Quality checks missed issues
needs fixingThe home's checks had not identified missing night-time fire drill records, the lack of an Accessible Information Standard policy or some medicines recording problems.
“Quality assurance systems had not always been effective in identifying areas for improvement and driving quality.” from the report
Care plans lacked detail
needs fixingSome care plans did not give enough information about communication needs or moving and handling equipment. The manager had planned training and improvements.
“Care plans were in place however some of them lacked detail, particularly in relation to communication needs and the use of moving and handling equipment.” from the report
- 01Has the manager's CQC registration application now been completed and accepted?
- 02How are you checking that patches, creams and as-required medicines are recorded correctly?
- 03How have you improved care plans for communication needs and moving and handling equipment?
- 04How do you make sure night staff take part in, and records are kept of, fire drills?
- 05What changes have been made following the action plan shared with the CQC after this inspection?
This was an unannounced planned inspection covering all five CQC questions, with the previous overall rating and four question ratings compared in the report. This explanation was written from the published report of 7 September 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 Saviours Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- September 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 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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