CQC report explained · a nursing home
What the CQC found at St Winifred's Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found safe medicine systems, effective safeguarding arrangements, risk assessments and enough staff to meet people's needs. Infection prevention and control arrangements were also found to be effective.
- Effective?
- Good
- This area was not looked at in detail during this focused inspection. The previous rating was used when calculating the overall rating.
- Caring?
- Good
- This area was not looked at in detail during this focused inspection. The previous rating was used when calculating the overall rating.
- Responsive?
- Requires improvement
- This area was not looked at in detail during this focused inspection. The previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found strong leadership, thorough audits and improved care records. The provider and manager had an action plan for further improvements.
What inspectors found, August 2021
Rated Good; inspectors found safe, caring support and strong management after improvements since the previous inspection.
This was an announced focused inspection. Inspectors checked whether earlier problems with medicines and care records had been fixed. They visited on 8 and 15 July 2021 and reviewed information off site on the other inspection dates.
The home was rated Good for Safe and Well-led. Inspectors found medicines were managed safely, risks were assessed, staff were safely recruited and infection control arrangements were in place. They also found enough staff to meet people's needs, although some people felt staff were busy and more staff were needed.
People, relatives and staff spoke positively about the home and its management. Audits and an action plan were being used to continue improvements. The previous overall rating was Requires Improvement, but the report says the earlier breaches had been resolved.
Safe medicines
Medicines were given safely and records were accurate and complete. Audits helped check that good practice was maintained.
“Medicine records were accurate and complete.” from the report
Positive leadership
The home was described as well run and organised. Leaders used audits, reflective practice and an action plan to improve care.
“Improvements had been made since the last inspection, all regulatory breaches had been met and the service was well run and organised with strong and effective leadership.” from the report
Kind care
People and relatives gave positive feedback about the care and said staff were kind, considerate and caring.
“They are always kind, considerate and caring. If you are having a down day, they pick you up” from the report
Staff can be busy
minorAlthough inspectors found enough staff and saw staff responding to people, some people felt staff were overworked and that it could take time to get help.
“Staff are lovely but overworked. Sometimes it takes a time to get anyone, depending how busy they are” from the report
- 01How many staff are normally on duty, and what happens when the home is particularly busy?
- 02What progress has been made with the planned new call bell system?
- 03Which parts of the refurbishment programme have been completed since this inspection?
- 04How do you check that medicine records remain accurate and complete?
- 05What were the previous problems with care records, and how are they now checked?
This was a focused inspection of Safe and Well-led, including infection control; the other ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 3 August 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, February 2020
St Winifred's Nursing Home was rated Requires Improvement; inspectors found kind and effective care, but serious medicines and record-keeping problems.
This was an unannounced, routine comprehensive inspection on 27 and 30 January 2020. Inspectors spoke with people, relatives, managers and staff, and reviewed care plans, medicines records and other documents.
The home was rated Requires Improvement overall. Safe, responsive and well-led were also Requires Improvement. Inspectors found problems with medicines storage, timing and records, unlocked areas, staff deployment, care plans and oral hygiene records.
Effective and caring were rated Good. People generally said they felt safe, were treated with dignity and received the food, drink, healthcare and activities they needed. Effective and caring had improved from Requires Improvement at the previous inspection.
The report says the home remained in breach of Regulation 12 on safe care and treatment and was also in breach of Regulation 17 on good governance. CQC said it would monitor the home and check that the required improvements were made.
Kind and respectful care
People and relatives spoke positively about the care. Inspectors saw staff being patient and supporting people at their own pace.
“We observed lots of nice, pleasant interactions between staff and people living at the home.” from the report
Support with food and healthcare
People received suitable food and drink, including modified meals where needed. Weight loss was monitored and referrals to healthcare professionals were made when appropriate.
“People's fluid intake records showed they received sufficient levels of fluids during the day.” from the report
Staff training and support
The home had induction, training, supervision and appraisal arrangements. Staff said they had enough training and support for their roles.
“Staff spoke positively of the training provided and said enough was available to support them in their roles.” from the report
Activities and community links
People could take part in games, exercises, entertainment, celebrations and trips into the local community.
“People were able to go on trips out into the local community, with people recently able to enjoy eating fish and chips on a nearby canal.” from the report
Medicines safety
seriousInspectors found medicines stored and recorded incorrectly, some doses given at the wrong time, and medicines fridge temperatures above the required level on 18 days. This was a continued breach and placed people at risk of harm.
“This placed people at risk of harm. This meant there had been a continued breach of regulation 12 (2) (g)” from the report
Unlocked areas and staff deployment
seriousA sluice room and electrical cupboard were easy to access. Communal areas were sometimes left without staff for long periods, and some people said they had to wait for help.
“Communal areas were left unattended for long periods at times throughout the day by staff, particularly in an area of the home known as Regency Suite.” from the report
Incomplete care records
needs fixingSeveral care plans did not explain people's communication needs, nail care or support with cleaning teeth or dentures. Oral hygiene records also had gaps, creating a risk that required care could not be confirmed.
“This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008” from the report
Audits did not identify problems
needs fixingAlthough audits were carried out, they had not identified the medicines and record-keeping concerns found by inspectors.
“Further improvements were required to ensure they were effective in identifying the concerns found during this inspection regarding medication and record keeping.” from the report
- 01What has been changed to ensure controlled drugs are stored and recorded correctly?
- 02How do you now check medicine timings, fridge temperatures and medication administration records?
- 03How are communal areas staffed so people are not left waiting or without supervision?
- 04How do you make sure care plans include communication, nail care and oral hygiene needs?
- 05What checks now confirm that oral hygiene support has been provided and recorded?
This was an unannounced comprehensive inspection covering all five CQC questions, including both the premises and the care provided. This explanation was written from the published report of 29 February 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 Winifred's Nursing Home
8 rated inspections over 6 years: the service has improved, from Inadequate to Good.
- August 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2019Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2018Inadequatestayed InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- February 2018Inadequatestayed InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- June 2017Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- July 2016Requires improvementup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015InadequateSafe: InadequateEffective: InadequateCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- September 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2013
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.
- January 2011
Registered with the Care Quality Commission on 25 January 2011.
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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