Background to this inspection
Updated
19 October 2023
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 Health and Social Care Act 2008.
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 2 inspectors and an Expert by Experience.
An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. The Expert by Experience undertook phone calls to relatives following our visits to the service.
Service and service type
St Lukes Care Home is a ‘care home.’ People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Lukes Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager for the service.
Notice of inspection
This inspection was unannounced. Inspection activity started on 24 August 2023 and finished on the 11 September 2023.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used all this information to plan our inspection.
The provider had not been asked to complete a Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make.
During the inspection
As part of this inspection we spoke with the manager, the deputy manager, the service manager and the nominated individual/Registered manager. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with 4 members of care staff and 2 members of Kitchen staff.
We spoke with 5 people living at the service and 4 relatives. We observed people being supported at the service. We reviewed a mix of care records of 9 people, including care plans, risk assessments and monitoring information. We reviewed 5 staff files.
Updated
19 October 2023
About the service
St Lukes Care Home is a residential care home providing regulated activities of personal and nursing care to up to 32 people. At the time of our inspection there were 22 people using the service.
People’s experience of using this service and what we found
The manager had been in post approximately 2 months, during this time they had worked with the provider to improve the standard of care for people. There had been significant improvements in people’s care. However, we would need to see these improvements seen at this inspection, sustained over a longer period of time to be assured good outcomes for people would be maintained.
The majority of personal risks to people’s safety were well managed. We highlighted an area in one person’s care plan which needed further information to support the person.
The management of medicines had improved but there were still further improvements required, such as ensuring medicines were dated when opened. Some as required medicines lacked a reason for their administration on their medicines administration record (MAR).
The manager was receptive to our feedback on these issues and addressed the concerns straight away.
Quality monitoring processes at the service had improved but aspects of these processes needed further refining. This included the issues we found with medicines and monitoring of personal care. The provider and manager was receptive to our feedback and assured us they had plans to further improve their auditing processes.
Assessments of people’s needs had been undertaken using nationally recognised assessment tools, and measures to reduce risks had been put in place using these risk assessments.
People told us they felt safe at the service. The management team worked with the provider to ensure all safeguarding concerns were dealt with appropriately. There were processes in place to enable learning from events. People were supported by adequate numbers of staff who had been recruited safely and received appropriate training for their roles.
People lived in a clean environment and although there were areas which needed to be refurbished the provider was aware of this and had a plan in place to prioritise the works required.
People’s nutritional needs were well managed, they enjoyed the food served to them. They were given choice and supported with their meals by a staff group who showed good knowledge of their nutritional needs.
Peoples’ health needs were well managed and there were good working relationships with external health professionals to provide good outcomes for people.
People were supported by a staff group who treated them with respect and maintained their dignity. They were supported to be involved with their care, which was provided in a person-centred way. Staff had good knowledge of people’s needs and used their care records to ensure people’s current needs were met.
People were supported to maintain relationships with their families and there were various leisure and event opportunities planned to reduce people’s feelings of boredom or isolation.
The service had systems to manage complaints and concerns from people or their relatives and people told us they felt listened to.
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 CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 25 May 2023). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
This service has been in Special Measures since 25 May 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection. The overall rating for the service has changed from Inadequate to Requires Improvement based on the findings of this inspection.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.