We carried out a review of the data available to us about St Theresa's Rest 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 Theresa's Rest Home, you can give feedback on this service.
St Theresa’s Rest Home is a residential care home for older people with varying physical and emotional needs including some people who are living with dementia. At the time of this inspection there was 23 people living at the service.
At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
At this inspection we found the service remained Good.
People told us that they felt safe living at St Theresa’s Rest Home. Care staff were able to give examples of they would identify potential abuse and the actions they would take to protect and safeguard people from abuse.
Risk assessments were detailed and person-centred and gave clear information and guidance on how care staff were to support people with their identified risk and to keep them safe and free from harm.
Systems and processes were in place to ensure people received their medicines safely, as prescribed and on time.
Recruitment processes followed by the service enabled them to only recruit staff that had been assessed as safe to work with vulnerable adults.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People were supported to live a healthy lifestyle and maintain positive well-being. People had access to a variety of health and social care professionals to enable this.
Staff were supported through training, supervisions and annual appraisals to effectively carry out their role.
People were observed to enjoy their meals and confirmed that they were always given choice and offered an alternative where a meal was not of their liking. People always had access to snacks and drinks of their choice.
People and their relatives knew who to speak with if they had a complaint to raise. They were confident that if they did raise a concern that this would be dealt with immediately and appropriately.
Care plans were person centred and gave detailed information to care staff on how to support people according to their needs and preferences.
We observed caring and respectful interactions between people and care staff. People had established positive relationships with all staff who worked at St Theresa’s.
People and their relatives knew the registered manager very well and felt confident in approaching them and the management team at any time.
Management oversight processes in place allowed the service to check the quality of care and support that people received so that where required the appropriate improvements, learning and development of the service could be implemented.
Further information is in the detailed findings below.
After the last inspection in November 2015 enforcement action was taken whereby the service was issued with a warning notice to make immediate improvements linked to Regulation 17, good governance. In addition to the warning notice a notice of proposal with positive conditions was served in relation to Regulation 12, safe care and treatment, where the service were required to submit monthly audits in relation to the safe management of medicines. Requirement actions were also required in relation to Regulation 11, need for consent and Regulation 13, safeguarding service users from abuse and improper treatment.
A focused inspection was carried out in January 2016 which looked at the safe management of medicines and was in response to the warning notice that had been issued. The service had made considerable improvements and the service was re-rated as ‘requires improvement’ in the ‘safe’ domain.
The providers’ response to the notice of proposal was positive and over a five month period the service consistently submitted evidence as per the requirements of the notice of proposal. The notice of proposal was withdrawn in May 2016.
During this inspection on 30 June 2016 and 1 July 2016 we found that the provider had implemented a number of systems and processes which had resulted in the provider no longer being in breach of the regulations which had been identified at the previous inspection in November 2015.
St Theresa’s Rest Home provides accommodation and support with personal care for up to 23 people. At the time of our inspection there were 12 people using the service.
A registered manager was in post and was available throughout the inspection process. 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.
We observed people to be happy and smiling as we entered the home and greeted everyone in the morning. People told us that they liked living at the home and felt safe and well supported by the care staff. We saw that people had developed positive relationships with each other as well as with the staff team within the home.
Care staff that we spoke with were aware of safeguarding, the different types of abuse, how to protect people from abuse and ensure their safety within the home. Care staff also knew what ‘whistleblowing’ meant and external agencies they would be able to contact to report any concerns. The service had a number of systems in place to protect people which included robust recruitment checks, staff training and individualised risk assessments for each person using the service.
At the previous inspection in November 2015 a number of issues had been identified around the safe management of medicines. A focused inspection in January 2016 found that the service had made significant improvements. During this inspection we found that the service had sustained the improvements that they had made and the service was found to be consistently managing medicines in a safe manner.
The registered manager and care staff had a good level of understanding around the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Care staff were able to give examples of ways in which both these pieces of legislation impacted on the care and support that they provided to people, especially where obtaining consent was concerned. The service had submitted DoLS applications for all people where applicable. DoLS are required to be in place to ensure that where an individual is being deprived of their liberty, that this is done in the least restrictive way.
Care staff had the required skills and knowledge necessary to support people with their care needs. Care staff told us they were able to request any additional training from the provider that was required to fulfil their role effectively and this was provided. Examples of how care staff respected people’s privacy and dignity were observed as well as given to us when speaking to them. People told us that care staff listened to them and respected their choices and decisions. We observed positive and meaningful interactions between people and care staff.
At the last inspection we identified that there was a lack of documentation available relating to the management of the home. This included documents in respect of staff supervisions, appraisals, staff meetings and handover notes. During this inspection we found that the service had made significant improvements in these areas and appropriate records were being maintained.
A number of systems and processes were in place to monitor and improve the quality of the service. This included a number of detailed medicine audits, care plan audits and a variety of health, safety and environmental checks. Enhanced environmental checks were also being completed in light of the refurbishment and building work that was being completed within the home.
We observed meal times to be a positive experience for all people living at the service. People eagerly awaited their meals and thoroughly enjoyed the food that was provided. We observed people to have access to a variety of drinks and beverages throughout the day. A menu was on display and people were asked their choices on the day. In addition to this, a bespoke and personalised preference sheet was also on display which outlined individual people’s likes, dislikes and alternatives that they would prefer.
People and relatives knew who the manager was and felt comfortable in approaching them if they had any concerns or issues that they needed to raise. Care staff told us that they enjoyed working at the service and that their priority and focus was that of the people they supported.
At the time of this focused inspection there was a manager in post. 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.
At the previous inspection on 3 November 2015, we found that some aspects of medicine management were not safe and this was a breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered provider did not ensure that people who used services and others were protected against safe management of medicines. Due to the serious nature of the breaches we took enforcement action against the registered provider.
After the inspection on 3 November 2015, the provider wrote to us to say what they would do to meet the legal requirements for the breaches we found. The provider confirmed that they would complete daily and weekly medicine audits and as part of that process would also review Medication Administration Records (MAR) for each person using the service. The provider also stated that they would review staff medicine training and ensure that all staff who administered medicines undertook a medicine competency assessment.
We undertook this unannounced focused inspection on 28 January 2016 to check the breaches in legal requirements to Regulation 12, concerning medicines and Regulation 17, having effective systems in place to monitor the quality and safety of service provision had been addressed. During this inspection we found that the legal requirements for Regulation 12 and 17 had been met.
This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for St Theresa’s Rest Home on our website at www.cqc.org.uk. We will undertake another unannounced inspection to check on all other outstanding legal breaches identified for this service.
We inspected the service on 3, 4 and 6 November 2015. The inspection was unannounced but was a follow up inspection after the inspection on 10 February 2015. During the last inspection the service ‘required improvement’ overall and was found to be inadequate in the ‘safe’ domain. The service was found to be in breach of regulations 13, 10 and 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which were the regulations we used at the time. The breaches were in relation to poor management of medicines, poor assessment and monitoring of quality of the service and lack of training records for staff members. Some improvements had been made since the last inspection. However, we found that there were still a number of concerns that had not been addressed.
St Theresa’s Rest Home provides accommodation for up to 23 people who require accommodation and support with personal care. The home has three floors. There is a lounge, conservatory, bedrooms, main kitchen and the manager’s office situated on the ground floor and bedrooms situated on the first and second floor. There is a lift for access to the first and second floor. At the time of our inspection there were 16 people using the service.
At the time of our inspection there was a registered manager in post. 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.
We spoke with people living at the service and they told us that they were happy with the service they received and were positive about the staff who provided the service. We saw people being treated with warmth and kindness and that staff were aware of people’s individual needs and how they were to meet their needs. People told us that staff supported them where necessary and encouraged them to remain independent. Relatives told us they were happy with the care that their loved one received and professionals had recorded positive statements about the service as part of peoples care reviews.
There were systems and processes in place to protect people from harm. These included safe recruitment practices, staff training and risk assessments that considered the individual potential risks for each person using the service.
There were some aspects of medicine management that were not safe. Although some improvements had been made since the last inspection there were some issues that had not been addressed. Controlled drugs were not managed safely. Some medicines were not stored safely. Medicine stock records were not maintained and there was a lack of guidance and appropriate paperwork for people whose medicine was being crushed or administered covertly.
Systems were in place to monitor and improve the quality of the service. Improvements had been made since the last inspection to ensure these systems were applied regularly. However, some of the systems were still not effective as they failed to identify re-occurring issues in respect of medicines and documentation relating to the management of the home.
All staff including the registered manager had a good understanding of the Mental Capacity Act 2005 and were able to demonstrate a good knowledge base on how to obtain consent from people. Staff files looked at also confirmed that staff had received training in this area. However, since the last inspection the registered manager had not implemented the principles of the Mental Capacity Act 2005 (MCA) especially where Deprivation of Liberty Safeguards (DoLS) were applicable. DoLS are required to be in place to ensure that where an individual is being deprived of their liberty that this is done in the least restrictive way. The service had only submitted a total of two DoLS applications and it was evident primarily due to locks and restrictions on the door that DoLS applications may apply to more people using the service.
At the last inspection there was lack of documentation available relating to the management of the home. This included a lack of documentation in respect of supervisions meetings, appraisals and staff meetings. During this inspection the same issues were again identified.
We found the home to be clean and free from odours. There was a record of health and safety, cleanliness and maintenance checks that had been carried out. There was also refurbishment work being carried out on the day of the inspection. The registered manager told us that refurbishment work was scheduled to be completed over the next six months which included re-decoration and improvements to the laundry and kitchen area.
People told us that the food was good at the home and that they enjoyed their meals. The chef was aware of people’s likes and dislikes and also of anyone with a special diet. Relatives were also very positive about the food.
Staff had the appropriate knowledge and skills necessary to support the people who used the service. People told us that staff listened to them and respected their choices and decisions. Staff also told us that they always ensured that when caring for people the most important thing was providing them with dignity and respect.
Staff were positive about working at the home and felt that they were supported well by the registered manager.
We saw positive interactions between staff members and people living at the service. During the inspection there was some activity taking place but some people were involved in their own activity like reading books. People and relatives told us that although there was some activity taking place, there could be more taking place.
People using the service, relatives and staff were positive about the registered manager. They knew who the registered manager was and felt confident in approaching them whenever they had any issues or concerns. Professionals that we spoke to also told us that they had no concerns with the quality of care provided and had no overall concerns.
We have made a number of recommendations in relation to the service’s policies and procedures and improved signage around the home.
We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
This unannounced inspection of St Theresa's Rest Home took place on 10 February 2015. This care home provides accommodation and personal care for a maximum of 23 older people, some of whom have dementia. At the time of our inspection 18 people were using the service.
At our last inspection on 21 January 2014 the service did not meet Regulation 10 (1)(b) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. At that inspection, the service did not have specific risk assessments and risks to people were not always being monitored on a regular basis. Therefore the service did not have an effective system in place to identify, assess and manage the risks to the health, safety and welfare of people who used the service. Our inspection on 10 February 2015 found that the service had specific risk assessments for people and these were being monitored on a regular basis.
There was a registered manager in post. 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 who used the service told us they felt safe in the home. Relatives of people who used the service told us that they were confident that people were safe in the home. The provider had taken steps and arrangements were in place to help ensure people were protected from abuse, or the risk of abuse.
We found that some aspects of medicines management were not safe. The service was not following current guidance and regulations about the management of medicines. Some medicines were not stored safely, some medicines records were not up to date, and controlled drugs were not managed safely. This meant that people were not protected against the risks associated with the unsafe storage and recording of medicines.
People were cared for by staff who were supported to have the necessary knowledge and skills they needed to carry out their roles and responsibilities. Care staff spoke positively about their experiences working at the home and the support they received from the registered manager and their colleagues. We noted there was a lack of documentation to confirm that staff had received medicines training and made a recommendation in respect of this.
We saw people who used the service were treated with kindness and compassion by care staff. People were being treated with respect and dignity and care staff provided prompt assistance but also encouraged and promoted people to build and retain their independent living skills.
People received personalised care that was responsive to their needs. Care plans were person-centred and specific to each person and their needs. We saw that people’s care preferences were also reflected. Risk assessments had been carried out in respect of various risks posed to people who used the service. People we spoke with were not positive about the activities available to them at the home and we saw a lack of evidence to confirm that people were involved in regular activities. In light of this we made a recommendation that further activities were available to people in the home.
During the inspection we found that there was a lack of documentation available relating to the management of the home. This included a lack of documentation in respect of supervision meetings, induction, appraisals and staff meetings.
Systems were in place to monitor and improve the quality of the service. However, the system was not effective as it failed to identify the issues in respect of medicines and documentation relating to the management of the home.
Professionals who provided us with feedback stated that they were satisfied with the quality of care provided and there were no concerns regarding communication.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
People with dementia and their relatives who we spoke with were very positive about the care provided by the manager and staff at the home. One person commented 'everything we ask for, they try and get us.'
Throughout the inspection visit we observed staff involving people in decisions about their care and respecting their preferences. People with dementia that we spoke with told us they were involved in making decisions about their care. One person commented 'they always ask. You can say yes or no it's up to the person.'
The care and treatment plan for people with dementia was based on their initial assessment of needs and involved a number of health and social care professionals including doctors, nurses, occupational therapists and social workers. However, we noted that identifying and monitoring people's potential risks to their safety and well-being were not always consistent.
People with dementia and their relatives told us they were satisfied with the way the home met their healthcare needs. Records we saw indicated that people had good access to dentists, opticians and chiropodists on a regular basis.
The service had a number of quality assurance initiatives to ensure that the quality of care provision was monitored and included the views of people with dementia and their relatives.
People using the service said 'the staff were very good and the manager excellent.' They said they were free to take up hobbies and were treated with respect. Some people were unable to comment as they had dementia but they had indicated to their relatives that they felt well cared for. Relatives said that they found the staff very caring and were confident of the care that their relative was receiving. People who use the service and relatives said that they felt confident in approaching staff and the manager if they were unhappy about anything. People spoken with said that they were able to go out on outings in the local community and staff tried to encourage them to be involved but respected people's choice if they did not want to.