CQC report explained · a nursing home
What the CQC found at St Winifreds Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved risk assessments and care records, safer medicines management, suitable staffing and appropriate infection control. The home was no longer in breach of Regulation 12.
- Effective?
- Good
- People's needs were assessed and reviewed. Staff training was up to date, and people were supported with nutrition, health conditions and healthcare appointments.
- Caring?
- Good
- This question was not assessed during this focused inspection. Its rating was carried over from the previous comprehensive inspection.
- Responsive?
- Requires improvement
- This question was not assessed during this focused inspection. Its rating was carried over from the previous comprehensive inspection.
- Well-led?
- Good
- Management checks and audits had improved. The manager and provider had better oversight of medicines, care plans, infection control and risks.
What inspectors found, January 2021
St Winifred's is rated Good; inspectors found improvements in safety, staff training and management, with no current legal breaches.
This was an unannounced focused inspection over three days in December 2020. Inspectors reviewed care records, medicines records, staff recruitment and supervision files, and management records. They spoke with people living at the home, staff and relatives.
The home was rated Good for Safe, Effective and Well-led. Inspectors found clearer risk assessments, safer medicines records, up-to-date staff training and better checks on the quality of care. Infection control measures for the pandemic were also in place.
The home had previously been rated Requires Improvement, with breaches relating to safe care, person-centred care and good governance. Inspectors found the required improvements had been made. This inspection did not assess Caring or Responsive, so those ratings came from the previous comprehensive inspection.
Clearer risk information
Care plans gave staff specific guidance about conditions such as epilepsy and diabetes. Staff could explain what action to take when risks arose.
“Improvements had been made to people's risk assessments and care records.” from the report
Safer medicines
Medicines records and audits had improved. Staff had clearer instructions, including for medicines given only when needed.
“Previous concerns that were found around hand written MARs had been rectified and staff had clear guidance to follow.” from the report
Prepared staff
Staff training, including refresher training, was up to date. Inspectors observed staff using suitable moving and handling techniques.
“All training was up to date, including refreshers, this was confirmed by reviewing training records.” from the report
Better management checks
The home had strengthened its audits and acted when problems were found. Staff and relatives said management was approachable and kept them informed.
“Improvements had been made to the quality assurance processes within the service.” from the report
Support for family contact
During the pandemic, the home introduced a visiting pod and a system to share pictures and videos with relatives.
“A visiting pod had been designed to help people see their loved ones during the pandemic.” from the report
Surveys were paused
minorThe home's surveys were on hold during the pandemic and the wording needed updating. The home used newsletters, meetings and informal conversations instead.
“During the current pandemic surveys had been put on hold.” from the report
- 01How do you now gather formal feedback from residents and relatives, following the pause in surveys?
- 02How are my relative's risk assessments and care plans reviewed when their health or needs change?
- 03How do you check that medicines records remain accurate, including medicines given only when needed?
- 04What were the Caring and Responsive ratings from the previous comprehensive inspection, and what has changed since then?
- 05How will you continue to monitor infection control and family visiting arrangements?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and their previous ratings were carried over. This explanation was written from the published report of 14 January 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, January 2020
Rated Requires Improvement; inspectors found kind care and enough care staff, but serious problems with medicines, risk assessments, care records and management oversight.
This was an unannounced inspection on 2 and 4 December 2019. It followed concerns about medicines, staffing, wound care and care planning. The inspector spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records.
People were treated kindly and respectfully. They had choices about meals and activities, and the home was clean. There were enough care staff to meet people's needs, although much nursing care was provided by regular agency nurses.
Inspectors found risks were not always assessed or explained to staff. Medicines were not always managed safely. Some care records were inaccurate or late, and checks by managers had not identified these problems. The home breached three regulations covering person-centred care, safe care and treatment, and good governance.
The overall rating was Requires Improvement. Safe, Effective, Responsive and Well-led were rated Requires Improvement, while Caring was rated Good. All five ratings had been Good at the previous inspection, published on 29 January 2019.
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff speak calmly, reassure people and respect their privacy and dignity.
“People told us staff were kind and caring.” from the report
Enough care staff
Inspectors found enough care staff to meet people's needs, and people were helped promptly when they used their call bells. The home did rely heavily on agency nurses.
“There were enough care staff to meet people's needs.” from the report
Food and mealtimes
People had meal choices and could request alternatives. Staff supported people patiently and provided specialised diets where these were needed.
“People were supported to eat a balanced diet.” from the report
Activities and relationships
People could take part in activities such as crafts, quizzes and reminiscence. Staff also supported visits, home visits and important relationships.
“People were supported to take part in activities they enjoyed.” from the report
Clean environment
The home was clean and free from unpleasant smells. Staff had suitable infection control training and protective equipment was available.
“The service was clean and odour free.” from the report
Risks were not managed consistently
seriousSome people did not have clear guidance about seizures, wounds or diabetes. Inspectors found an incident where a recorded seizure lasted 50 minutes but emergency medicine had not been given.
“Potential risks to people's health and welfare had not been consistently assessed.” from the report
Medicine safety
seriousSome required signatures were missing, instructions for 'when required' medicines lacked important details, and medicine strengths were not always recorded clearly. Staff corrected some pharmacy instructions during the inspection.
“Medicines were not always managed safely.” from the report
Care records were inaccurate
seriousRecords were not always complete or timely. Food and fluid charts were inaccurate, and some care plans gave conflicting or unclear instructions.
“Records of the care and support people received were not accurate.” from the report
New admission lacked a care plan
seriousOne person with complex health needs had no assessment or care plan 11 days after admission. The assessment and a short care plan were completed during the inspection.
“Since their admission, there had been no assessment of their needs or care plan written.” from the report
Weak management checks
seriousThe manager and provider had not carried out comprehensive audits until shortly before the inspection. Complaint investigations, staff supervision records and meeting minutes were also incomplete.
“The registered manager had not completed checks and audits on the work of the lead nurse.” from the report
- 01What changes have been made to medicine checks, including 'when required' instructions and the required signatures?
- 02How are seizure, wound, diabetes and specialist mattress risks now assessed and explained to staff?
- 03How do you check that new residents have a complete assessment and care plan soon after admission?
- 04How are care records, food and fluid charts, and repositioning records checked for accuracy?
- 05What evidence can you show that the action plan and improved audits have been completed?
This was an unannounced inspection covering all five CQC questions, including the premises and care provided, prompted by concerns about medicines, staffing, wound care and care planning. This explanation was written from the published report of 8 January 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 Winifreds Care Centre
4 rated inspections over 5 years: the service has held its Good rating throughout.
- January 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- January 2020Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 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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