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CQC report explained · a residential care home

What the CQC found at St Vincent House - Gosport

Requires improvementpublished 16 November 2022, 3 years ago

Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.

The five questions inspectors ask
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.
The latest report, explained

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.

What inspectors praised
  • 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
What inspectors were concerned about
  • Incomplete risk information

    serious

    Some 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

    serious

    The 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 fixing

    Staff 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

    serious

    Audits 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

    minor

    There 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
Questions to ask them, based on this report
  1. 01How have you checked that every person's care plan now gives clear, specific guidance about health needs and falls risks?
  2. 02How do you monitor people who are in communal areas or moving around independently, and where are staff positioned to reduce risks?
  3. 03How do you record when topical creams are opened, and how is this checked in medicine audits?
  4. 04What changes have you made to ensure accidents and incidents lead to prompt reviews and clear records of lessons learned?
  5. 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.

An earlier report, explained

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.

What inspectors praised
  • 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
What inspectors were concerned about
  • Loose landing carpet

    needs fixing

    Inspectors 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 fixing

    Decisions 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

    minor

    There 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
Questions to ask them, based on this report
  1. 01Has the loose carpet on the upstairs landing now been replaced?
  2. 02How are best-interest decisions about shared bedrooms recorded and reviewed?
  3. 03Who currently organises activities while the activities coordinator post is being filled?
  4. 04How are people's individual activity choices and time in the community supported?
  5. 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.

The story over the years

Every inspection of St Vincent House - Gosport

5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.

  1. November 2022Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at St Vincent House - Gosport →

  2. September 2018Good
    Safe: GoodWell-led: Good

    Read what inspectors found at St Vincent House - Gosport →

  3. October 2017Inspected but not rated
    Safe: Inspected but not ratedWell-led: Inspected but not rated

    Read this report on cqc.org.uk

  4. April 2017Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  5. April 2016Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. June 2015Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  7. September 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. April 2014

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. May 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. February 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  11. October 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  12. October 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  13. 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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