Archived: St Audrey's

Updated 15 May 2025

Assessment activity took place between 28 May 2025 and 10 July 2025. St Audrey’s is a residential care home. It provides accommodation with personal care to up to 35 people across 3 floors. At this assessment 9 people were living at the service. This assessment was carried out to follow up on breaches identified at our last assessment. We looked at all quality statements as part of this assessment.

We visited the service on 28 May 2025. This was an unannounced visit completed by 1 inspector and an expert by experience. We received feedback from 13 staff and 3 professionals. We spoke with 1 person who used the service and 6 relatives. At our last inspection, in July 2024, we rated the service requires improvement and identified breaches in relation to medicines management, infection prevention and control, managing risk, staff competency, safety of the environment, person-centred care, and management oversight. We found the service had improved but remained in breach of regulations in relation to person-centred care, managing risk and good governance.

The provider’s processes to monitor food and fluid intake were not always effective and people remained at risk of social isolation due to a lack of activity and stimulation. The environment remained in a poor state of repair.

People’s care records included some personalised information but there was a lack of detail about their life history and interests. We found some staff interactions tended to be mainly task-focused with a lack of social interaction.

The provider had not ensured the service had stable and effective leadership. There had not been a registered manager since October 2022 and this continued to impact on staff, and people’s relatives were unsettled by the lack of stability of the service. However, the current manager told us they had started the process to register with CQC.

The provider’s governance processes had not been very effective. While the provider’s checks had identified concerns related to the quality and safety of people’s care, these were not always actioned in a timely way for the necessary improvements to take place. We received mixed feedback from staff about feeling supported and able to raise concerns with the manager.

Staff supervisions and competency assessments were completed. People’s medicines were managed safely. The home was clean.

The manager communicated well with other health professionals and people were supported to access other services as required. People’s mental capacity assessments (MCA) demonstrated how they were involved and supported with decisions.

People’s care records included guidance for staff in how to support people to maintain their independence and make choices. Most people and relatives described staff as kind and caring.

We have written to the provider to ask for an action plan about how they will improve the quality and safety of the service where there were breaches of regulations.

Updated 15 May 2025

People’s care was not always person-centred. There was a lack of detail in people’s records about their backgrounds and wishes at the end of their life, and relatives were not always included in reviews of people’s care.

People’s relatives told us there continued to be a lack of activities available for people, but they were aware an activities coordinator had been recruited. People’s skin integrity was monitored regularly and whilst we found re-positioning records were not always robust, at the time of our inspection no one had any pressure injuries. People’s relatives had no concerns about how people’s medicines were managed.

Most people and their relatives told us staff were kind and caring. However, some felt not all staff had the required knowledge to care for them safely and compassionately. Staff were aware of people’s special diets and knew their likes and dislikes. People confirmed staff gained consent before providing care, so their rights were respected.