We carried out a review of the data available to us about St Saviours Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Saviours Care Home, you can give feedback on this service.
We found the following examples of good practice.
Visitors were protected from catching and spreading infection. The home was closed to all but essential visits on the day of our inspection due to an ongoing outbreak of COVID-19. Visitors were asked to complete a Lateral Flow Device test (LFD) before they entered to ensure they were not infected. The home provided appropriate personal protective equipment (PPE) to accommodate visits. This included face masks and aprons.
People who tested positive for COVID-19 were asked to self-isolate in their own bedrooms for 14 days. People who completed their isolation period were able to access communal areas, however some people decided to continue to stay in their bedrooms. People had been supported to socially distance.
People's health and wellbeing was monitored using nationally recognised physical deterioration and escalation tools. People were observed for symptoms of COVID-19 and other potential infections. Healthcare professionals had continued to provide clinical support to people when it was required.
People were supported and encouraged to maintain contact with their relatives via phone calls and video calls.
Staff had received training in donning and doffing their PPE. There were multiple PPE stations available for staff throughout the home. We observed staff were wearing PPE in accordance with the latest guidance.
The testing scheme for all staff and residents had been conducted – known as ‘whole home testing’. Testing had helped the registered manager identify when full infection control measures needed to be implemented and when staff needed to self-isolate.
The home environment was clean. Domestic staff had designated areas they cleaned throughout their shift.
The provider had robust contingency plans in place to ensure the safety of the service during the pandemic.
People’s experience of using this service and what we found
There was no manager registered with the commission. During the inspection the manager and provider had confirmed that an application to register had been submitted and the manager was waiting for a registration interview. There was no record of an application having been received and the provider was unable to provide us with evidence by way of a reference number to confirm the application had been. This limits the rating of well-led as the registered managers condition has not been met. Since the inspection site visit we have received an application to register however it was returned due to being incomplete.
The management team were aware that some areas such as documentation and care planning needed to be further developed. During the inspection we identified additional areas, including the recording of some medicine applications and documenting night staff involvement in fire drills. There was no direct impact on people however we have made a recommendation about the management of medicines and a recommendation about quality assurance procedures.
People told us they felt safe and were supported by kind and caring staff. Staff knew people well and had developed warm, caring and compassionate relationships with people. People were treated with dignity and respect; their independence was encouraged and were possible people were involved in decision making about their care.
Staff told us they were well supported and had access to a range of training which meant they were able to meet people’s needs. Healthcare professionals involved in supporting the home commended staff in relation to supporting people nutritionally with fortified meals and drinks before making a referral for prescribed supplements and also in relation to end of life care.
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.
Communal areas were themed which provided people with the opportunity for reminiscence. People could personalise their rooms and benefited from fully accessible, beautifully maintained garden areas.
A range of activities were available, including a dementia café. Activities co-ordinators were attending additional training in relation to activities for people living with a dementia and people with sensory needs.
People’s needs were assessed before they moved into the service. This information was used to develop care plans and ‘snapshots’ of care which provided a summary of people’s needs. The manager was making improvements to care plans to ensure they were detailed and personalised.
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 Good (published 14 July 2017).
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The service had a registered manager working at the service. However she had stepped down from the overall management of the service and was undertaking a supportive role for an associated manager who had recently been employed. We discussed with the provider and associate manager that the Care Quality Commission would require them to register with us as they were undertaking the role and responsibility of a registered manager. Both the provider and associate manager told us they would be making this change in the near future. 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 were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The manager shared information with the local authority when needed.
The risks to people’s safety were assessed when they were admitted to the service and measures identified to reduce the risks however there were occasions when measures in place to reduce the risk were not in place.
People received their medicines as prescribed and the management of medicines was safe.
Staffing levels were sufficient to support people’s needs and people received care and support when required. Medicines were managed safely and people received their medicines as prescribed at the times they needed them
People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We also found staff were aware of the principles of the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.
People were protected from the risks of inadequate nutrition. Specialist diets were provided if needed. Referrals were made to health care professionals when needed.
People who used the service, or their representatives, were encouraged to contribute to the planning of their care.
People were treated in a caring and respectful manner and staff delivered support in a relaxed and considerate manner.
People who used the service, or their representatives, were encouraged to be involved in decisions and systems were in place to monitor the quality of service provision. People also felt they could report any concerns to the management team and felt they would be taken seriously.
We spoke with three relatives about their views of the home. We observed the support staff gave to people who used the service. We also looked at records, including care files of four people and carried out a tour of the building.
We found people gave consent to their care and received care and support which met their needs. A person told us, 'I am very independent and can choose what I want to do, the help is there if I need it.'
We asked people who used the service what they thought of the food that was provided for them. One person told us, 'The cook is very good and the dinners are lovely. The food is always hot.'
We saw the building was clean, safe and well maintained and the provider assessed and monitored the quality of the service provided.
We found the service was well led.
People told us they had enough information to tell them about what the home provided when they moved in, that they could express themselves in the way they wished and were encouraged to make their own choices.
One person told us, "There is always something to do that we have chosen to do. Anyone with any common sense will tell you that this is a good home."
People also said they felt safe living at the home. They told us that they were confident that staff had the right skills and experience for the job and that they were honest and trustworthy. One person said, 'They (staff) look after us well. My daughter always says she goes home contented knowing I am safe here.'
We found that people and staff felt confident taking any suggestions or concerns to the deputy manager and the manager. A relative of one person told us, "The manager and carers are always here to raise any questions or queries with."