Caritate Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We found a breach of the legal regulations. Auditing systems were not robust. Records of incidents were not consistently analysed to help identify patterns and themes. Action plans were not developed in response to identified concerns. However, a new manager had been appointed and had identified areas for improvement. The manager was working with staff to proactively drive improvement in the service. Staff were positive about the changes.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff had confidence in the new manager. Comments included; “Given the time and the chance I am sure (the manager) will enhance the home” and “There is a new manager in post with a very good base knowledge and experience.” The manager had identified people were not always offered meaningful occupation. They were working to identify staff who could offer additional activities to people during the day.

The manager had only been in post one week at the time of the inspection. They told us they were well supported by the provider and were applying to be registered with CQC. Other senior staff told us they were also able to contact the provider for advice and guidance at any time.

Some staff told us they were able to contact the provider directly if they felt that was necessary. Other staff were less confident about raising concerns with leaders. We fed this back to the new manager who said they were planning to speak to all staff and encourage them to feedback any issues they had.

Staff views had been collected using a survey and some areas for improvement were identified. However, no action plan was in place to address the issues raised. Staff meetings had not been held regularly. The last one recorded took place in September 2023. The manager and staff told us meetings were being organised for all staff. These were due to take place the week following the inspection.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There were clear lines of responsibility and accountability and these were understood by staff. The new manager told us they would discuss introducing a system of key workers with the staff team.

Records were held securely. A new electronic recording system had recently been introduced and staff were confident using this. Statutory notifications had been submitted to CQC in line with legal requirements.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager had plans to gather the views of all stakeholders to identify areas for improvement. For example, they were arranging initial supervisions when they were planning to ask staff for any suggestions and identify staff strengths and areas of interest. They told us they were keen to enable all staff to voice their opinions about how the service was organised. A member of staff described a recent occasion when they had made a suggestion about someone’s care, and this had been listened to and acted on. They commented; “I’ve noticed, even this fortnight, the carers are being listened to more.”

Processes to ensure learning occurred when things went wrong were not robust. We saw records of an incident which was a potential safeguarding concern. There was limited information on what action had been taken in response. Accidents and incidents were recorded but there had been no analysis of the records since December 2023. There was limited evidence of any actions in place to mitigate the risk of incidents reoccurring. Some people were at risk due to low fluid intake. Staff recorded how much fluid people had received. There was no evidence any action was taken when fluid targets were not met. A staff survey had been completed and some negative feedback received. There was no action plan in place to address the issues raised. A complaint had been raised by a relative in relation to the care provided. This had been dealt with in a timely manner and to the satisfaction of the family.