CQC report explained · a nursing home
What the CQC found at St Thomas' Priory
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Hawksyard Priory Nursing Home rated Requires Improvement; inspectors found serious gaps in recruitment, medicines, risk management and dignity.
This was an unannounced inspection on 4 and 11 April 2023. Inspectors spoke with people, relatives and staff. They reviewed care records, medicines records, policies and building safety records, and observed care in communal areas.
The home had enough staff overall and people said they felt safe. Food choices, healthcare support and infection control were positive. However, staff were not always recruited safely. Medicines were not always managed safely, risks were sometimes missed, and building safety problems were not always dealt with promptly.
People were not always treated with dignity or offered choices. Activities did not meet everyone's needs, and communication support was not always planned. The overall rating and all five question ratings were Requires Improvement. The home remained in breach of regulations from the previous inspection.
Staff available
Inspectors found enough staff overall, and people said staff responded when they needed help.
“When I press my buzzer they come straight away all the time, day or night. There's enough staff here to support me all the time.” from the report
Health support
People were supported to access health professionals, and their health needs were monitored when needed.
“People were supported to access other health professionals and had their health needs assessed and monitored, when needed.” from the report
Reported improvement
People, relatives, staff and a health professional said the home had improved since the previous inspection or management changes.
“Absolutely without a doubt the home has improved. The new team are more aware of what they need to do to be better and proactive at putting that into place.” from the report
Recruitment checks
seriousEmployment histories, proof of address and right-to-work checks were not always complete. Checks were also missing for some staff living in the home and for contractors working unaccompanied.
“Staff were not always recruited safely, and we could not always be sure of staff member's suitability to work in the service.” from the report
Medicines
seriousOne person received an overdose of a short course of medicine. Instructions for some medicines and reviews of covert medicines were not always clear or up to date.
“One person had an overdose of a short course of medicines and staff had not identified this.” from the report
Risk and building safety
seriousSome risks and conflicting care-plan information were not identified or managed. Problems with emergency lights, fire doors, electrical safety and water temperatures were not always dealt with promptly.
“Risks to people had not always been identified, assessed, and planned for.” from the report
Dignity and choices
seriousInspectors saw people not always being offered choices or spoken to during care. One person who was coughing while eating was not supported until an inspector intervened.
“People were not always treated with dignity and respect and not always given choices.” from the report
Activities
needs fixingPeople said they were bored and wanted more activities. The limited activities resource was also sometimes used to observe communal areas instead.
“People were not always supported enough to partake in enough activities of their choice.” from the report
Communication support
needs fixingSome people's individual communication needs were not recorded or supported consistently. Staff had not all been helped to understand one person's sign language.
“People did not always have tailored support planned for and in place to support their individual communication needs.” from the report
- 01What has been done to make sure every staff member and contractor has completed recruitment and suitability checks?
- 02How do you now prevent medicine errors, and how are covert medicines reviewed with relatives and professionals?
- 03How are care plans and risk assessments checked for conflicting or out-of-date information?
- 04What repairs and safety actions have been completed for fire doors, emergency lighting, electrical safety and water temperatures?
- 05What extra activities and communication support are now available for people with different needs?
This was an unannounced follow-up inspection prompted partly by recruitment concerns and partly by the previous inspection; all five areas were rated, with Caring and Responsive inspected for the first time. This explanation was written from the published report of 14 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, January 2023
Hawksyard Priory Nursing Home is rated Requires Improvement; inspectors found medicine and care-record safety problems and issued a warning notice.
This was an unannounced focused inspection on 17 November 2022. Inspectors reviewed 16 care records and several medicines records. They spoke with people living at the home, relatives and staff.
Inspectors found important problems with medicines. Some medicines were not in stock, topical creams were not always recorded as given, and records did not always show that patches had been removed or applied safely. Care plans and risk assessments were also not always accurate or up to date.
Staff were safely recruited and infection control arrangements were satisfactory. People had access to healthcare, their weights were monitored, and care plans included people's preferences. However, training, staffing information and management checks were not always effective.
The overall rating and the ratings for Safe, Effective and Well-led were Requires Improvement. This means care was not consistently safe or effective and there was limited assurance about safety. The home was newly registered, but the previous provider's service had been rated Inadequate in September 2022.
Safe recruitment
The home carried out checks on new staff, including Disclosure and Barring Service checks.
“For example, the registered manager completed checks on new staff around their suitability to work by the Disclosure and Barring Service (DBS).” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Personalised care records
Care plans included people's preferences, and people and relatives had some involvement in planning care.
“People's care plans were personalised and contained details of their preferences.” from the report
Access to healthcare
People had regular GP visits, and staff made referrals when people's healthcare needs changed.
“A weekly health visit was completed by the GP to review people's care and treatment.” from the report
Medicines were not always safe
seriousSome medicines were out of stock or not recorded as given. Records about creams and transdermal patches were incomplete, creating a risk of harm.
“Medicines were not administered safely. An effective system was not in place to ensure people did not run out of medicines.” from the report
Care plans did not always manage risks
seriousSome care plans lacked clear, current instructions. Inspectors found unclear guidance about seizure support and repositioning to reduce pressure damage.
“People's care plans and risk assessments did not contain accurate and up to date details of their known needs and risks.” from the report
Training was not consistently effective
needs fixingSome staff had not completed safeguarding or Mental Capacity Act training, and staff did not always understand training they had completed.
“New staff had limited guidance around training priorities.” from the report
Management checks missed problems
seriousAudits did not identify all the concerns found by inspectors. Where problems had been identified, action was not always completed promptly.
“Systems were not in place or not effective at identifying where improvements were required and ensuring timely action was taken to make these improvements.” from the report
Staffing levels needed review
needs fixingPeople did not have to wait during the inspection, but staff feedback and gaps in pressure-relief support led inspectors to recommend reviewing staffing against people's needs and risks.
“We recommend the provider review people's needs alongside staffing levels to ensure people receive timely access to staff support.” from the report
- 01What has changed to make sure medicines are always in stock and that creams and transdermal patches are given and recorded safely?
- 02How are you checking that each person's care plan and risk assessment reflects their current needs, including seizure support and pressure relief?
- 03Which staff have completed safeguarding and Mental Capacity Act training, and how do you check that they understand it?
- 04What staffing review has been completed against people's needs and risks, and how will you prevent delays in pressure-relief care?
- 05What action has been taken in response to the warning notice, and what evidence can you show that the improvements are working?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and were not given ratings. This explanation was written from the published report of 11 January 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.
Every inspection of St Thomas' Priory
2 rated inspections over a year: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2023Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- October 2022
Registered with the Care Quality Commission on 11 October 2022.
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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At least 100 live-in carers within about an hour of Staffordshire
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