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Archived: St.Theresa's Nursing Home Inadequate

Inspection Summary

Overall summary & rating


Updated 29 November 2016

We carried out this unannounced comprehensive inspection of St Theresa’s nursing home on 1November 2016. We undertook this visit as we had received concerns in respect of the care and welfare of people using the service. We looked at the concerns raised, plus we checked what action the provider had taken in relation to concerns brought to the commission’s attention during our last inspection in January 2106. At that time we found a breach of legal requirements, in that new staff were starting work at the service without a satisfactory Disclosure and Barring Service (DBS)check in place. We received information of concern prior to this inspection that a person had been allowed to work alone with vulnerable people before required checks had been completed. We discussed this with the manager who confirmed this to have occurred. A record showed a DBS check for a staff member appointed in August 2015 had not been requested until June 2016. The failure to complete necessary checks before allowing staff to provide care exposed people to unnecessary risk. This was a repeated breach of regulation requiring action to be taken from the comprehensive inspection in January 2016.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Theresa’s Nursing Home on our website at The provider for this location is registered under the legal entity of Morleigh Limited which is part of a group of nursing and residential care homes.

St Theresa’s is a care home which provides accommodation for up to 45 people who require nursing care. At the time of the inspection 22 people were living at the service. Most people who lived at St Theresa’s required general nursing care due to illness. Some people were living with dementia. St Theresa’s is a purpose built single storey building with a range of aids and adaptation in place.

The 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. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. St Theresa’s has been without a registered manager since March 2014. Since that time five managers have been appointed. Two of those managers left after a short employment period at St Theresa’s. One was moved to manage another service in the group and then left. One was moved from another service in the group to manage St Theresa’s on a part time basis and the current manager commenced in October 2016.This has meant there has been no management stability at the service. The current manager told us they had submitted an application to the commission for registration. However, this could not be verified at the time of the inspection visit and was not found to be the case following the inspection.

Medicines were not being managed safely. Handwritten entries were not always double signed. There were gaps in records of when creams had been applied and not consistently signed as given. There were inaccurate records of the amounts of medicines being stored. Medicines were not being returned to the pharmacist as required. Medicines requiring cold storage were being stored at above the recommended temperature range. This had been identified by the manager but not acted upon.

The premises and equipment were not being maintained in a safe and secure way. The collection of soiled laundry from bedrooms and cleaning procedures did not ensure suitable standards of cleanliness. There was no designated facility to wash commode bowls effectively. A broken shower door was propped against a wall in the bathroom. Water temperatures were inconsistent with one hot bath tap supplying water at a temperature above the safe range. A door to a store room which contained cleaning products was left open and

Inspection areas



Updated 29 November 2016

The service was not safe. Medicines were not being managed safely. Records were not accurate and were not being signed.

The service was not ensuring recruitments checks were in place before staff began working with vulnerable people.

The service was not ensuring potential hazards within the environment were being addressed.


Requires improvement

Updated 29 November 2016

The service was not always effective. People were not always satisfied with the quality and choice of meals.

Maintenance of the service was not always taking place as necessary.

Staff had access to training in order for them to develop skills in their role. However, there was no system in place to assess staff competencies.


Requires improvement

Updated 29 November 2016

The service was not always caring. People were not always treated in a respectful way when requesting care and support.

Staff understood the need to protect people�s privacy and therefore their dignity.

Some people who used the service and some relatives were positive about the care they received.


Requires improvement

Updated 29 November 2016

The service was not always responsive. There were gaps in some care records which meant staff did not always have the information to respond to people�s needs.

Care plans did not always provide staff with clear information about how to respond to a person�s needs.

Care plans were not always updated which meant information may not be accurate and affected how staff responded to people�s needs.

The range of activities available to people was limited and not always meaningful, specifically where people had dementia care needs.



Updated 29 November 2016

The service was not well led. The provider has a regulatory history of multiple breaches of regulations and required enforcement action which continue.

There has been no continuity in the management of the service due to frequent changes of manager. A registered manager is a condition of the registration of the service.

We found a number of concerns during our inspection which had not been identified by the provider or manager. This showed a lack of robust and effective quality assurance systems.

Records relating to the management and running of the service and people�s care were not consistently maintained.