CQC report explained · a residential care home
What the CQC found at St Vincent House - Gosport
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks, including falls and known health needs, were not fully recorded or assessed. Medicine systems were mostly in place, but checks on topical creams and some PRN guidance needed improvement.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was used in the overall rating.
- Well-led?
- Requires improvement
- There was a management structure and provider oversight, but audits had not identified all concerns or ensured prompt action. Care records and risk assessments needed more detail.
What inspectors found, November 2022
St Vincent House - Gosport is rated Requires Improvement; inspectors found kind care but gaps in risk records, medicines checks and management oversight.
This was an unannounced focused inspection. One inspector visited on 10 October 2022, with inspection activity continuing until 19 October. The inspector spoke with five people, eight staff members, seven relatives and outside professionals. They observed care and checked care plans, medicine records, staff files and management records.
The home was not always safe. Some care plans did not give enough detail about health needs and falls risks. Records about topical creams, accidents, incidents and some mental capacity assessments also needed improvement. The home had enough staff and safe recruitment systems, but staff deployment in communal areas needed review.
People said they felt safe and described staff as kind and caring. Safeguarding arrangements, infection control, environmental safety and most medicine systems were in place. The management team responded quickly during and after the inspection and updated some records and checks.
The overall rating changed from Good at the previous inspection in September 2018 to Requires Improvement. Only Safe and Well-led were inspected this time. The ratings for the other questions were carried over from the previous inspection.
Kind and caring staff
People, relatives and outside professionals described staff as kind, friendly and supportive. Staff knew people well and were observed speaking with patience.
“We observed a calm, friendly and supportive atmosphere in the service.” from the report
Enough staff
The provider had increased staffing and inspectors found there were enough staff to meet people's needs. The location of staff still needed reviewing for people at risk in communal areas.
“There were enough staff available to sufficiently meet people's needs.” from the report
Safe recruitment
Recruitment checks included DBS checks, current references and investigation of gaps in employment.
“There were safe and effective recruitment procedures in place to help ensure only suitable staff were employed.” from the report
Safeguarding arrangements
Staff understood how to recognise and report abuse. Safeguarding incidents had been reported appropriately to the relevant organisations.
“All staff we spoke with had a good understanding of their safeguarding responsibilities.” from the report
Infection control
Inspectors were assured that the home had up-to-date infection control policies and was following government guidance.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Incomplete risk information
seriousSome care plans did not contain enough specific information about known health needs and falls risks. This could leave staff without clear guidance unless the improvements made after inspection are maintained.
“Risks to people were assessed but some risks had not been identified within people's care plans or needed further detail, to ensure staff had clear guidance about how to manage them.” from the report
Falls risks in communal areas
seriousThe home needed to assess risks more fully when people were in communal areas or moving around independently. It also needed to show how staff deployment would reduce these risks.
“These risks had not been fully assessed or records made to demonstrate how they would be reduced.” from the report
Topical medicines
needs fixingStaff had not recorded when creams were opened, so it was not clear they would always be discarded by their use-by date. The medicine audit had also not checked this.
“The date creams had been opened had not been recorded by staff, to ensure they were disposed of when they reached their 'use by' date.” from the report
Slow management action
seriousAudits had identified some problems, but action had not always been taken promptly. The report said people were left at risk while improvements were delayed.
“However, although these had identified some of the concerns we found, action was not taken promptly, which meant people were left at risk.” from the report
No registered manager
minorThere was a manager in post who was applying to register, but no registered manager was in place at the inspection.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01How have you checked that every person's care plan now gives clear, specific guidance about health needs and falls risks?
- 02How do you monitor people who are in communal areas or moving around independently, and where are staff positioned to reduce risks?
- 03How do you record when topical creams are opened, and how is this checked in medicine audits?
- 04What changes have you made to ensure accidents and incidents lead to prompt reviews and clear records of lessons learned?
- 05What is the current position of the manager's application to register with CQC?
This was an unannounced focused inspection of Safe and Well-led only; the other question ratings were carried over from the previous inspection in September 2018. This explanation was written from the published report of 16 November 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.
What inspectors found, September 2018
Rated Good; inspectors found safe, kind and personalised care, with a few minor records and maintenance points to check.
This was an unannounced comprehensive inspection on 16 and 18 July 2018. Inspectors spoke with people living at the home, visitors, staff and healthcare professionals. They also observed care and checked care plans, medicines, staffing, recruitment, complaints and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable risk assessments, kind care and care plans that reflected people's individual needs.
The home had improved since the February 2017 inspection, when it was rated Requires Improvement and was in breach of five regulations. At this inspection, inspectors found those improvements had been made and there were no current breaches.
Personalised risk support
Risks were assessed for each person and regularly reviewed. Staff were given clear guidance to support people safely while promoting independence.
“Risk assessments were personalised and provided sufficient information to allow staff to protect people whilst promoting their independence.” from the report
Kind and respectful care
Inspectors saw staff speaking patiently and warmly with people. Staff respected privacy, dignity and people's choices.
“People felt the staff were kind and caring.” from the report
Safe medicines
Medicines were stored, administered and audited through suitable systems. Staff had training and clear guidance for medicines given when needed.
“People's medicines were managed safely on their behalf.” from the report
Good care planning
Care plans included people's preferences, histories, relationships and specific needs. Families were involved where appropriate.
“People's care plans were person centred and staff had the information they needed to support them as individuals.” from the report
Improved management
Quality checks, care records and action plans had improved since the previous inspection. Staff said the home was better supported and run.
“Quality assurance systems had been improved and become embedded in day-to-day systems and management.” from the report
Loose landing carpet
needs fixingInspectors found a loose section of carpet upstairs that could cause a trip. The home had identified it, put temporary measures in place and scheduled replacement, but inspectors advised doing this as soon as possible.
“However, we observed an area of carpet on the upstairs landing that was a little loose and could cause a tripping hazard.” from the report
Shared-bedroom records
needs fixingDecisions about people using shared bedrooms had not been recorded in the same format as other best-interest decisions. The manager said the records would be updated.
“However, decisions about people using shared bedrooms had not been recorded in the same format as other best interest decisions.” from the report
Activities coordinator vacancy
minorThere was no activities coordinator in post when inspectors visited. The home had interim arrangements, including sharing an activities coordinator with another home and involving care staff.
“At the time of the inspection there was no activities coordinator in post.” from the report
- 01Has the loose carpet on the upstairs landing now been replaced?
- 02How are best-interest decisions about shared bedrooms recorded and reviewed?
- 03Who currently organises activities while the activities coordinator post is being filled?
- 04How are people's individual activity choices and time in the community supported?
- 05How will you tell us if our relative's risks, medicines or care needs change?
This was an unannounced comprehensive inspection covering all five CQC questions, with observations, discussions and checks of care, staffing, medicines and management records. This explanation was written from the published report of 21 September 2018 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of St Vincent House - Gosport
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- November 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2018GoodSafe: GoodWell-led: Good
- October 2017Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- April 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 17 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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