St Anthony's Residential Home Limited

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

At our last inspection, we found the providers quality assurance systems were not effective and there was a lack of processes for gathering feedback from people and their relatives. This contributed to a breach of the regulations. At this inspection, we again found that the provider’s quality assurance and auditing systems were ineffective. In addition, the registered manager was regularly absent from the service and did not fully understand their role and responsibilities. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Notifications had not been submitted to the Commission in line with legal requirements. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. The provider now has some systems in place to document feedback from people, their relatives, and staff. Compliments had been regularly received.

This service scored 46 (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.

The registered manager was still not routinely in charge of the service and had a relatively limited understanding of how the service operated. The registered manager was regularly absent from the service and told us, “I am here half the time and half the time in Wales.” The Director and deputy manager were normally responsible for the service’s day to day operations. Staff told us the registered manager was not ‘up to date’ and said, “We all look at [the director] as the boss. No one really looks at [the registered manager] as the boss”. From discussions with the deputy manager and the director it was clear they did not fully understand what was required to achieve compliance with the regulations. The recently promoted deputy manager was well motivated and keen to learn. Staff were complimentary of the deputy manager and told us, “I go to [The deputy manager, they] get things sorted” and “[The deputy manager] is great”.

A number of individuals raised concerns about the approach of the provider’s director who they described as, “difficult”. Throughout the assessment the director was civil but challenging. The specific concerns people raised were discussed and investigated during the assessment. The inspectors worked with the director to help them understand and recognise how changes in approach could impact positively on both the service’s performance and the quality of support people received. When present, the registered manager provided a compassionate and caring example to the staff team. They had encouraged and supported staff to help people maintain their links with the local community.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Staff told us they had received regular supervision from senior carers and the deputy manager. Records showed staff meetings had been held regularly and provided opportunities for staff and leaders to discuss issues and challenges within the service. One staff member told us, “We had a team meeting about a month back. The director got Chinese food in and we had a quiz as well”. The staff team were well motivated and dedicated to the people they supported. The service had regularly received compliments from people's relatives and surveys had been used to gather feedback. The specific roles and responsibilities of the registered manager, director and deputy manager were not clearly defined or understood by the staff team.

The provider’s quality assurance systems were ineffective and had failed to ensure the service was compliant with the requirements of the regulations. Accurate records had not been maintained of investigations into staff performance issues. Regular audits had not been completed to monitor the service’s performance and there were no formal systems in place to enable the registered manager to effectively monitor the service’s performance during their regular absences. The provider had not submitted any notifications to the Commission since 2019. Records viewed during the assessment process demonstrated multiple notifiable events had occurred. The Provider had a policy detailing what information should be notified to the Commission, but this policy had not been followed.

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.

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