St Luke's Care Home

Updated 8 September 2021

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 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.

Service and service type

St Luke’s 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.

The service had a manager registered with the Care Quality Commission. 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.

Notice of inspection

We gave 24 hours’ notice of the inspection. Due to the COVID-19 pandemic we wanted to review documentation remotely and make arrangements to speak with staff by telephone after our site visit. This helped minimise the time we spent in face to face contact with the manager and staff. Inspection activity started on 29 June 2021 and ended on 13 August 2021. We visited the service on 29 June 2021.

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, local safeguarding team and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all of this information to plan our 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.

During the inspection

We spoke with five people who used the service about their experience of the care provided. We spoke face to face with the regional manager, registered manager, clinical lead and a nurse. We spoke by telephone with six members of care and nursing staff. We spent time observing the care and support people received. We reviewed three people’s medicines records.

After the inspection

We reviewed a range of records. We reviewed most of the documentation remotely by asking the registered manager to send us key information before and after our site visit. This included three people’s care records. We looked at three staff records in relation to recruitment and reviewed the staff training overview. A variety of records relating to the management of the service, including audits, policies and procedures were also reviewed.

We continued to seek clarification by telephone from the registered manager to validate evidence found.

Updated 8 September 2021

About the service

St Luke’s Care Home provides nursing and personal care for a maximum of 34 older people. At the time of our inspection there were 23 people living at the service. The home provides single room accommodation with most rooms having en-suite facilities.

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

Quality assurance systems were in place but had not identified or addressed all the shortfalls we found during the inspection. Although people told us they felt safe at the service, we found inconsistencies with information around risks to people and how staff should respond to these. Records had not always been completed accurately to show whether care tasks had been carried out.

We found some improvements were needed to fully ensure the safe management of medicines. The registered manager immediately addressed some of these shortfalls during our inspection, but there was further work to be done to ensure changes were embedded into practice; particularly of care records. We have recommended the provider reviews care records more robustly to ensure their accuracy and that they keep medicines under review to ensure the improvements made are sustained.

Staffing levels were appropriate to meet people's needs. Staff were trained in safeguarding and appropriate referrals had been made to the local authority. Staff ensured people lived in a clean and tidy environment. Infection prevention and control practices had been updated to follow government guidance. Some renewal of carpets and décor were needed, and the provider had a plan in place to address this.

Staff were kind and caring and people provided positive feedback about staff. We observed good interactions between people and staff. Staff treated people with dignity and respect and knew their needs well.

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.

People told us they enjoyed the food and they were involved in aspects of their care; particularly around what time they would like to get up or go to bed. People said they made their own decisions. They also told us they would have no hesitation in raising a concern or complaint with staff or the management team.

Staff told us they enjoyed working at the service and felt well supported by the management team. They said the service was managed well. The management team were receptive to our feedback and responded to address concerns and improve the service; such as those we found related to medicines.

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

Rating at last inspection

The last rating for this service was ‘inspected but not rated’ (published 21 September 2020).

Why we inspected

This was a planned inspection based on the previous rating.

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.

The overall rating for the service is requires improvement. This is based on the findings at this inspection.

You can read the report from our last inspection, by selecting the ‘all reports’ link for St Luke’s Care Home on our website at www.cqc.org.uk.

Enforcement

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.

We have identified a breach in relation to good governance and records at this inspection.

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 from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.