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Archived: St Josephs Requires improvement

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 October 2016

The inspection took place on 24 August 2016 and was unannounced. The previous inspection of 27 July 2015 found the service required improvement. There were breaches in regulation that related to staffing levels, the environment and the systems in place to oversee quality and drive improvement. We followed up these areas at this inspection.

Since the last inspection there has been a change of provider and the new management team had begun to introduce new systems and procedures. We found substantial progress had been made but the service was not yet providing safe and effective care for all the people who lived there. The environmental issue raised at the last inspection about access to and from the annex was not yet resolved. Therefore the requirement from the previous inspection remains outstanding. The provider has told us that there was a risk assessment in place to reduce the likelihood of harm and no admissions were planned to this part of the service. People living there had the opportunity to move into the main building and they were planning to undertake changes to the building to improve access although this requires approval from the planning authority. Therefore we plan to monitor this matter going forward, but will not escalate our powers of enforcement.

St Josephs is a care home for 60 older people some of whom are living with a diagnosis of dementia. The unit that accommodates people living with dementia is called Gainsborough and has twenty seven bedrooms and a separate living space. The service also has an annex with a separate living area which adjoins the main home. On the day of our inspection there were 46 people in total living in the service.

A manager was new post and had commenced employment three months prior to the inspection. The manager told us that they had made an application for registration to become the registered manager for St Josephs. 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.

People told us that they liked living in the service and that they felt safe and well cared for. Staffing levels had been identified as problematic at the last inspection but we found improvements had been made. People were supported by a stable staff team and there were sufficient numbers of staff available to respond to people’s needs and keep them safe. Robust recruitments systems were in place to check on new staff suitability for the role.

Medicines however were not consistently well managed and while we found examples of good practice we also found omissions in the management of controlled medications and topical creams. The manager had already identified the issues about creams and had a plan to address this. They took steps to immediately address the other issues by undertaking supervisions and increased auditing.

Risks were identified and there were systems in place to ensure that people at risk had access to equipment to protect them, such as hoists and pressure relieving mattresses. Checks were undertaken to make sure that equipment was working effectively and the environment was safe.

A programme of training was underway to ensure that staff skills and knowledge was up to date. While this was not yet complete and there remained some shortfalls, there was greater oversight and more effective planning.

People had good access to health care professionals when they needed support or treatment. However we found that the support provided to people with specific health conditions such as diabetes needed to be strengthened and staff provided with clearer guidance to prevent harm.

People liked the food and the meals served looked nutritious and nicely presented. People told us that they had good relationships wit

Inspection areas


Requires improvement

Updated 4 October 2016

The service was not consistently safe.

People�s medicines were not always consistently well managed.

Risks were identified and there was a plan in place to manage them and reduce the risks of harm.

Staffing levels met the needs of the people resident.

Staff had a good understanding of how to respond to and report allegations of abuse.


Requires improvement

Updated 4 October 2016

The service was not consistently effective

Parts of the service were not suitable for the intended purpose and placed people at risk.

People had access to routine healthcare appointments. Staff skills and knowledge in the management of specific health conditions should be strengthened to prevent harm.

Staff received induction and ongoing training. While there remains some gaps in staff knowledge there was greater oversight of training and a plan to address them.

Staff were clear about their role in supporting the principles of choice and consent and had training in the Mental Capacity Act and associated Deprivation of Liberty Safeguards.

People were supported to maintain a healthy diet.



Updated 4 October 2016

The service was caring

People had positive and caring relationships with staff.

People were treated with compassion and kindness.

People were involved in decisions about how they were supported and their independence was promoted.

People's privacy and dignity was promoted.



Updated 4 October 2016

The service was responsive.

People had a care plan which was known by staff and reflected their preferences.

People had access to activities which promoted their wellbeing.

Peoples experience was taken into account and they were systems in place to consult with them. There were systems in place to address concerns and complaints.



Updated 4 October 2016

The service was well led.

There was an open culture and people were positive about how the service was managed.

The manager was visible and accessible and known to the people who lived in the service.

There were systems in place to look at quality and drive improvement.