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Archived: St Andrews Court Inadequate

Inspection Summary

Overall summary & rating


Updated 25 August 2020

About the service

St Andrews Court is a care home which is registered to provide personal and nursing care for up to 12 people with mental health needs. St Andrews Court accommodates 12 people in one adapted building and there were 12 people being supported at the time of our inspection.

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

Numerous incidents including abuse and/or allegations of abuse were not adequately responded to and escalated to relevant partner agencies such as the local authority. This meant people were not protected from harm. People did not all feel safe. Incidents including where people and staff had come to harm, were not learned from and risks were not adequately managed. This was a breach of the regulations.

We identified a second breach of the regulations due to inadequate risk management and further significant shortfalls in the safety of the service. People’s risks and complex needs were not adequately assessed and known to all staff, and the premises presented hazards and further risks to people’s safety. Where people’s risks were known to staff, they were not consistently managed. Systems also failed to ensure safe medicines management at all times.

We identified a third breach of the regulations because there were not enough suitably skilled and qualified staff, including nurses, to safely meet all people’s needs. This meant clinical support, agreed with local authorities, could not always be provided to people. Recruitment checks had been carried out appropriately and the home was clean.

People’s needs were not adequately assessed or always known to staff. This meant people’s needs could not always be met. People gave mixed feedback about the support provided. Staff did not have adequate training and guidance for their roles.

Staff did not always take care to ensure people had enough to eat. People’s choking risks were not effectively managed which put people at risk of harm. People gave mixed feedback about the food; some people made and prepared their own meals.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the systems in the service did not support good practice and we identified a fourth breach of the regulations, around consent.

The provider failed to ensure the service was adapted to meet all people’s needs. The service was decorated in a homely way. Staff helped people to access healthcare support.

We identified a fifth breach of the regulations because the provider failed to consistently support people’s autonomy, independence and involvement in the community. Institutional practices negatively impacted on people’s dignity, privacy and positive experiences. People were not all encouraged to have control and choice as far as possible.

People were not always well treated and supported, and people’s diverse needs were not always met. Staff often had a caring approach, but this was not consistent. People were not adequately supported to have their needs heard and met.

We identified a sixth breach of the regulations because people did not all receive personalised care and were not empowered to have choice and control over their care. People were not involved in care plan reviews, and the views people expressed were not always listened to. Care planning failed to ensure everyone had good access to activities and have their communication needs met. People did not show full confidence in the complaints process.

We identified a seventh breach due to the provider’s continued failure to notify CQC of specific events and incidents at the service as required by law.

We identified an eighth breach related to the provider’s poor governance systems which exposed people to ongoing risk of harm and poor care. Our inspection found widespread and significant shortfalls in the quality and safety of the service. Systems failed to ensure risks and incidents

Inspection areas



Updated 25 August 2020

The service was not safe.

Details are in our safe findings below.



Updated 25 August 2020

The service was not effective.

Details are in our effective findings below.



Updated 25 August 2020

The service was not caring.

Details are in our caring findings below.



Updated 25 August 2020

The service was not responsive.

Details are in our responsive findings below.



Updated 25 August 2020

The service was not well-led.

Details are in our well-Led findings below.