CQC report explained · a residential care home
What the CQC found at St Vincents Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough suitably recruited staff, detailed risk assessments, safe medicines arrangements and appropriate infection control. Some as-required medicines plans lacked important details on the first day, but this was addressed immediately.
- Effective?
- Good
- People's needs were assessed and reviewed, staff had relevant training and supervision, and people could access healthcare professionals when needed. Inspectors found that consent and best-interest arrangements followed the law.
- Caring?
- Good
- People and professionals described staff as kind and caring. Inspectors observed patient, respectful support and found that people were involved in decisions about their care.
- Responsive?
- Good
- Care plans were detailed, personalised and regularly reviewed. People had choices about daily life, activities suited their interests, and arrangements helped them stay in touch with loved ones during COVID-19 restrictions.
- Well-led?
- Good
- Inspectors found effective quality checks, an open management culture and good partnership working. There was no registered manager at the time, but a new manager had been recruited and was due to start.
What inspectors found, July 2021
St Vincents Retirement Home was rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
Inspectors visited without notice on 10, 11 and 16 June 2021. They spoke with people, staff, relatives and health professionals. They also checked care records, medicines, staffing, recruitment, infection control, the building and management systems.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they were happy and felt safe. Inspectors found enough staff, detailed care plans, safe medicines systems and kind, respectful care.
The previous inspection, published in March 2020, had rated the home Requires Improvement and found several breaches of regulation. At this inspection, inspectors found that improvements had been made and the home was no longer in breach.
Enough staff
Inspectors found sufficient skilled staff to meet people's needs safely and without rushing. Staffing levels were reviewed according to people's needs.
“There was a relaxed atmosphere in the home and staff had time to chat to people and support them in a calm and unhurried way.” from the report
Personalised care
Care plans included people's histories, preferences, health needs and the level of support they needed. Staff knew people well and supported their choices.
“Information in care plans was robust and person centred and included details about people's life history, their likes and dislikes and specific health and emotional needs.” from the report
Kind and respectful support
People were treated with dignity and involved in decisions about their care. Inspectors saw positive relationships and patient support.
“We observed positive interactions between people and staff. Staff showed kindness and patience when talking to people and there was some natural banter which demonstrated positive relationships.” from the report
Good activities and contact
The home offered activities based on people's interests. During COVID-19 restrictions, staff helped people stay in contact with relatives through calls, written messages and technology.
“Activities provided included; trips out in the local community, arts and crafts, music, quizzes and exercises.” from the report
Improved management checks
Since the previous inspection, the home had introduced stronger checks and audits. Inspectors found that identified improvements were acted on promptly.
“Effective and robust quality assurance systems had been developed and implemented.” from the report
As-required medicines plans
needs fixingOn the first day, some plans did not clearly explain when medicines should be given, the expected result or what to do if they did not work. The acting manager took immediate action to address this.
“on day one of the inspection inspectors identified some of these plans did not include robust information in relation to when these medicines should be given” from the report
Manager registration
minorThere was no manager registered with the CQC when inspectors visited. A new manager had been recruited and was due to start after the inspection, with plans to complete registration.
“The service did not have a manager registered with the Care Quality Commission at the time of the inspection.” from the report
- 01What action was taken after the inspectors found missing details in some as-required medicines plans?
- 02Has the new manager started, and have they completed the CQC registration process?
- 03How are staffing levels checked when people's care needs change or staff are absent?
- 04How are relatives kept involved in care planning and reviews?
- 05How are activities matched to each person's interests, especially if COVID-19 restrictions affect outings or visits?
This was a planned, unannounced inspection covering all five CQC questions, including infection prevention and control; the previous Requires Improvement rating was reassessed and changed to Good. This explanation was written from the published report of 8 July 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, March 2020
Rated Requires Improvement; inspectors found kind staff and enough staffing, but identified risks, consent and management failures.
This was the home’s first inspection since registration. It was unannounced and took place on 21 and 24 February 2020. The inspector spoke with people, relatives, staff and healthcare professionals, observed care, and checked care, medicine, recruitment and management records.
The home was rated Requires Improvement in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, suitable training, positive relationships and activities that people enjoyed.
However, some people were put at risk. Inspectors found unsafe moving and handling after falls, missing window restrictors, no full professional fire risk assessment, gaps in medicine records, and care being given very early in the morning without proper consent or a best-interest decision.
The provider had to send CQC an action plan. The management team took some immediate steps during or after the inspection, but CQC said it would continue monitoring the home and check that improvements were made.
Kind and respectful staff
People and relatives spoke warmly about staff. Inspectors observed calm, patient and respectful interactions, including support for a distressed person.
“We observed positive interactions between people and staff. Staff supported people in a friendly, calm and patient way.” from the report
Enough staff
Inspectors found appropriate numbers of consistent, permanent staff. People and staff said there was enough time to provide care without rushing.
“People were supported by appropriate numbers of consistent, permanent staff.” from the report
Food and healthcare
People were positive about the food. Staff arranged healthcare support when needed and followed advice from healthcare professionals.
“People were encouraged to maintain a healthy, balanced diet, based on their individual needs and, where necessary, their intake was recorded.” from the report
Activities and relationships
People had regular activities, including music, crafts, reminiscence and visits. Relatives were welcome and were kept updated.
“People had access to a range of activities, including, movement to music, art/craft sessions, visits from animals and reminiscence sessions.” from the report
Clean environment
The home was described as warm and homely. Inspectors found regular cleaning, suitable infection control arrangements and five-star food hygiene.
“The local environmental health team had awarded the home five stars [the maximum] for food hygiene.” from the report
Environmental and falls risks
seriousMost windows could open wide enough for someone to fall from. Staff also manually helped people up after falls instead of using suitable equipment, creating a risk of physical harm.
“Most windows, except for a few on the ground floor, had not been fitted with window opening restrictors.” from the report
Unsafe falls procedures
seriousThere was no procedure for unwitnessed falls. Records did not show that people were always monitored for complications such as head injuries.
“The service did not have an unwitnessed falls procedure meaning staff may not know what actions they should take on finding a person that has fallen.” from the report
Medicine records and checks
seriousInformation about when some as-needed medicines should be given was incomplete. Checks of medicine stocks and administration were not always completed, and the effect of some medicines was not recorded.
“Monthly audits of medication were not always completed as per the provider's systems.” from the report
Care without proper consent
seriousTwo people were woken between 5 and 6 am and given full personal care without consent or a recorded best-interest reason. Required mental capacity assessments and some Deprivation of Liberty Safeguards applications were still being prepared.
“Providing care and treatment without the consent of the person or in their best interests following mental capacity legislation was a breach of regulation 11 of the Health and Social Care Act 2008 (regulated Activities) regulations 2014 (Part 3).” from the report
Weak quality checks
needs fixingThe home’s checks did not identify several problems found by inspectors, including safety, medicines, recruitment and consent issues. Some incidents had also not been reported to the relevant authorities.
“Management quality assurance systems were not always effective and failed to identify some of the concerns found on this inspection” from the report
- 01Have all window opening restrictors now been fitted, and has a suitably qualified professional completed the full fire risk assessment?
- 02What is the current procedure after a witnessed or unwitnessed fall, including checks for head injuries?
- 03How are as-needed medicines now linked to clear instructions, and how is their effectiveness recorded?
- 04Have all required mental capacity assessments and Deprivation of Liberty Safeguards applications been completed?
- 05How does the management team now check that care records, medicine audits, risk assessments and incident notifications are complete?
This was an unannounced first inspection of the care home, covering accommodation and nursing or personal care and all five CQC key questions. This explanation was written from the published report of 28 March 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 Vincents Retirement Home
2 rated inspections over a year: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2020Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019
Registered with the Care Quality Commission on 15 March 2019.
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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Most charge £1,010 to £1,230 a week. 68 can care for a couple. 11 years' experience on average.
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