St Catherines Care Home

Updated 23 September 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector.

Service and service type

St Catherines Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We gathered feedback from the local authority and other professionals who have visited the home since our last inspection.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with two people who used the service and five relatives about their experience of the care provided. We also spoke with 11 members of staff including the registered manager, clinical lead, nominated individual, nurse and five support workers.

Updated 23 September 2022

St Catherines Care Home is a care home providing nursing and personal care for up to 40 people, some of whom are living with dementia. There were 20 people living in the home at the time of the inspection.

People's experience of using this service and what we found

Improvements were needed to the governance systems within the service. There were failings by the provider in the way the service was led and managed. The systems in place for monitoring the quality and safety of the service were inadequate . They failed to identify and mitigate risk and bring about improvements to the service people received.

Records used to monitor, and review people's care had not been fully completed and kept up to date. We found examples where sections of care plans and care records had not been updated to reflect changes in their needs.

Staff were not recruited safely. Recruitment processes were not robust enough, staff files were disorganised and not always kept in one place; the registered manager told us they would work to improve the system.

Infection prevention and control practices were not always safe and did not protect people from the risk of infections. The kitchen was unclean and not well maintained.

Staff had not received all the training they needed to support people safely, for example safeguarding people from harm, infection prevention and control and managing fire safety.

We recommended the provider review their documentation in relation to end of life care and for the provider to ensure they support people to express their views and be involved in making decisions about their care.

We recommend the provider review how people are supported to maintain contact with relatives to avoid social isolation.

We received mixed feedback regarding staffing levels at the service. People, relatives and staff told us staffing levels were not always effective, particularly at weekends, to ensure people's needs were met in a timely way.

People and relatives told us staff were kind and caring and they treated them with dignity and respect.

People received their medicines as prescribed.

The registered manager was receptive to the inspection findings, they told us they were willing to learn, improve and share the actions that had taken or would take to address the issues found at this inspection .

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

This service was registered with us 12 October 2021 and this is the first inspection.

Why we inspected

This was a planned inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Catherines Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to monitoring and assessing risk, training, staff recruitment, infection prevention and control and oversight of the home.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.