CQC report explained · a nursing home
What the CQC found at St Teresa's Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, risk assessments, suitable recruitment checks and good infection control. Medicine trolley temperatures were above 25 degrees in all four areas, although the provider took action during the inspection.
- Effective?
- Good
- Staff had relevant training and the home followed the Mental Capacity Act. People were supported with nutrition and healthcare, but oral healthcare assessments and support were not consistent.
- Caring?
- Good
- Staff were observed treating people with kindness, dignity and respect. People were supported to make choices and maintain independence, although comments about involvement in care planning were mixed.
- Responsive?
- Good
- People had access to activities, visitors and personalised care plans. Inspectors found improvements in social dining and relationships, and complaints were handled through the home's processes.
- Well-led?
- Good
- Leadership and governance had improved, and audits were generally used to identify shortfalls. Some care records still contained inconsistent information, so the provider was recommended to keep reviewing its checks.
What inspectors found, July 2023
Rated Good after improvements; inspectors found kind, safe care, but some medicine, oral care and record-keeping issues remained.
Inspectors visited the home unannounced on 19, 20 and 21 June 2023. They spoke with people, relatives, staff and professionals. They also observed care and checked care plans, medicine records, maintenance checks and quality audits.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable training, safe infection control and kind treatment. People were supported with food, drink, healthcare, activities and contact with relatives.
There were some shortfalls. Medicine trolley temperatures were above the recommended limit, oral healthcare support was inconsistent and some records contained conflicting information. The provider acted during the inspection by adding medicine refrigeration, bringing forward air-conditioning plans and introducing a dental tracker.
The previous rating was Requires Improvement, published in November 2020, with breaches of regulation. Inspectors found enough improvement had been made and there were no current breaches. They made one recommendation to keep improving governance checks and records.
Kind and respectful care
Staff were observed treating people with dignity and respect. People said staff were kind, and inspectors saw staff protecting privacy and offering choices.
“We observed staff treating people with dignity.” from the report
Improved activities and social contact
People were supported to spend time with others, receive visitors and take part in activities. Inspectors found improvements since the previous inspection.
“At this inspection we found improvements had been made and relationships between people were now encouraged.” from the report
Staffing and training
Inspectors found sufficient staff to provide safe care. Staff had training relevant to moving and handling, safeguarding and equality, diversity and inclusion.
“Staff were supported to access training relevant to their roles.” from the report
Improved leadership
The home had improved its governance arrangements since the last inspection. Audits, action plans and leadership visits were being used to drive improvement.
“Overall, checks and audits were used effectively by the registered manager to identify shortfalls, errors and omissions and drive improvement in the service.” from the report
Medicine storage temperatures
needs fixingAll four medicine trolley areas were above 25 degrees, which was above the usual manufacturer guidance mentioned in the report. The provider added refrigerated storage and brought forward plans for air-conditioned medicine storage rooms.
“The temperature of medicine trolleys was above 25 degrees in all 4 areas.” from the report
Inconsistent oral care support
needs fixingSome people had not been asked whether they needed help registering with a dentist. A dental tracker and care-plan alerts were introduced during the inspection.
“People's experiences of oral healthcare assessment and support were inconsistent.” from the report
Conflicting care records
needs fixingSome records gave different information about a person's skin condition on the same day. Inspectors recommended further work to make governance checks consistently effective.
“We found some inconsistencies in the information documented by staff about care they provided.” from the report
Choices were not always clear
minorPeople gave mixed accounts about how consistently staff supported their preferred routines and choices, including when they wanted personal care.
“We received mixed comments from people about how consistently staff delivered care to in line with people's choices.” from the report
- 01How are medicine trolley temperatures checked now, and what happens if they rise above the recommended limit?
- 02How will you identify which residents need help registering with a dentist and keep their oral care up to date?
- 03How do managers check that care records are accurate and do not contain conflicting information?
- 04How are residents' preferred days and routines for personal care recorded and followed?
- 05How are residents and relatives told about ways to give formal feedback?
This was an unannounced follow-up inspection covering the home's premises and care, infection prevention and control, and action required after the previous inspection. This explanation was written from the published report of 13 July 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, November 2020
Rated Requires Improvement; safe care improved, but important care planning, consent, staffing and oversight breaches remained under review.
This was a focused inspection on 29 September 2020. Inspectors reviewed Safe and Well-led. They spoke with people, relatives and staff, examined care records, medicines, incident records, audits and recruitment records, and checked infection control arrangements.
The Safe rating improved from Inadequate to Good. Inspectors found that risks, medicines, safeguarding, staffing, equipment and infection control were generally managed safely. They also found some gaps in repositioning records and written instructions for barrier nursing.
The Well-led rating improved from Inadequate to Requires Improvement. Management systems had improved, but inspectors could not show full compliance with governance requirements. Continuing breaches from the previous inspection were not reviewed for person-centred care, consent and staffing.
The overall rating improved from Inadequate to Requires Improvement. The home had been in Special Measures since October 2019, but it was no longer in Special Measures after this inspection. The inspection did not review Effective, Caring or Responsive.
Improved safety
The home had addressed the environmental hazards found at the previous inspection and improved its systems for risk management, medicines and safeguarding.
“At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 12” from the report
Medicines management
Medicines records were complete when doses were given, and inspectors found that people received medicines as prescribed. Staff had medicines training and their competency was checked.
“At this inspection people's Medicine Administration Record (MAR) charts were completed when doses of medicines were given and people received their medicines as prescribed.” from the report
Safeguarding
Safeguarding concerns were identified, recorded and referred to the appropriate agencies. Staff knew how to report concerns inside and outside the home.
“Safeguarding concerns were identified, recorded and referred to the appropriate agencies, such as the local authority safeguarding team.” from the report
Staffing levels
People and staff told inspectors there were enough staff to meet people's needs. The home also had safe recruitment systems.
“There were enough staff available to support people safely and meet their needs.” from the report
Infection control
Inspectors were assured about the home's arrangements for PPE, testing, social distancing, admissions and preventing or managing infection outbreaks.
“We were assured that the provider was making sure infection outbreaks would be effectively prevented or managed.” from the report
Care plans and meaningful activity
seriousThis was a continuing breach from the previous inspection and was not reviewed during this visit. Some needs assessments did not contain current guidance, and people were not always supported with meaningful relationships and activities.
“Assessments of peoples' needs did not always contain current relevant information and guidance for staff.” from the report
Consent decisions
seriousThis was a continuing breach from the previous inspection and was not reviewed during this visit. Capacity assessments and best-interest decisions were not always completed in line with the Mental Capacity Act.
“Capacity assessments and best interest decisions were not always completed in line with the principles of the Mental Capacity Act (2005).” from the report
Governance and oversight
seriousGovernance systems had improved, but the home remained in breach because the inspection did not provide enough evidence of full compliance across all areas.
“we were unable to sufficiently evidence full compliance with Regulation 17.” from the report
Staff training
seriousThis was a continuing breach from the previous inspection and was not reviewed during this visit. Staff did not always receive training relevant to their roles and the people they supported.
“Staff did not always receive training relevant to their roles and to the people they were supporting.” from the report
Records of repositioning
needs fixingThere were gaps in records for two people being repositioned as set out in their care plans. The report says there was no evidence of an impact, but one refusal of support had not been recorded.
“We found there were some gaps in the recording for two people being repositioned in line with their care plan.” from the report
Communication with relatives
minorRelatives gave mixed feedback. Some felt communication was good, while others found it difficult to get through or wanted more contact.
“Some felt the communication had been good, whilst others stated they thought it could be better.” from the report
- 01What have you done to bring the continuing breach about person-centred care to an end, especially for keeping care plans current and providing meaningful activities?
- 02How do you complete and review capacity assessments and best-interest decisions for people who cannot make particular decisions themselves?
- 03What staff training is still outstanding, and how do you check that staff are competent for the roles and people they support?
- 04How are you checking that repositioning records are complete and that refusals of care are recorded?
- 05How will relatives receive regular updates, and what should we do if we cannot get through by phone?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not reviewed and their previous ratings were used for the overall rating. This explanation was written from the published report of 6 November 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.
Every inspection of St Teresa's Nursing Home
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- July 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Requires improvementup from InadequateSafe: GoodWell-led: Requires improvement
- October 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 2010.
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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