St Luke's Care Home

St Luke’s Care Home provides nursing and personal care for a maximum of 34 older people. At the time of our inspection there were 23 people living at the service. The home provides single room accommodation with most rooms having en-suite facilities.

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

Quality assurance systems were in place but had not identified or addressed all the shortfalls we found during the inspection. Although people told us they felt safe at the service, we found inconsistencies with information around risks to people and how staff should respond to these. Records had not always been completed accurately to show whether care tasks had been carried out.

We found some improvements were needed to fully ensure the safe management of medicines. The registered manager immediately addressed some of these shortfalls during our inspection, but there was further work to be done to ensure changes were embedded into practice; particularly of care records. We have recommended the provider reviews care records more robustly to ensure their accuracy and that they keep medicines under review to ensure the improvements made are sustained.

Staffing levels were appropriate to meet people's needs. Staff were trained in safeguarding and appropriate referrals had been made to the local authority. Staff ensured people lived in a clean and tidy environment. Infection prevention and control practices had been updated to follow government guidance. Some renewal of carpets and décor were needed, and the provider had a plan in place to address this.

Staff were kind and caring and people provided positive feedback about staff. We observed good interactions between people and staff. Staff treated people with dignity and respect and knew their needs well.

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.

People told us they enjoyed the food and they were involved in aspects of their care; particularly around what time they would like to get up or go to bed. People said they made their own decisions. They also told us they would have no hesitation in raising a concern or complaint with staff or the management team.

Staff told us they enjoyed working at the service and felt well supported by the management team. They said the service was managed well. The management team were receptive to our feedback and responded to address concerns and improve the service; such as those we found related to medicines.

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 ‘inspected but not rated’ (published 21 September 2020).

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service is requires improvement. This is based on the findings at this inspection.

You can read the report from our last inspection, by selecting the ‘all reports’ link for St Luke’s Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified a breach in relation to good governance and records at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St Luke’s Care Home provides nursing and personal care for a maximum of 34 older people. At the time of our inspection there were 21 people living at the service. The home provides single room accommodation with most rooms having en-suite facilities.

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

Overall, medicines were safely managed. However, we found improvements were needed. These included the administration of prescribed creams and more accurate recording around the use of prescribed thickening agents. We have recommended the service follows the NICE (National Institute for Health and Care Excellence) guidance, Managing Medicines in Care Homes. Published 14 March 2014.

People and their relatives told us they or their family members felt safe at the service. People were protected from abuse and avoidable harm. They were treated with respect and dignity. The provider maintained safe staffing levels to meet people’s needs. Risks to people’s health and safety were managed well, although some improvements on the completion of records to monitor people’s fluid intake were required. Staff followed national guidelines to prevent the spread of infection and to make sure the home was clean.

People said the home was well-run. They said the registered manager and staff were approachable and kind. The provider and registered manager demonstrated their commitment to continuous improvement of the service. The registered manager and staff promoted and encouraged person centred care to ensure people were treated as individuals. Audits and monitoring procedures were used effectively to monitor the service and to make improvements. When accidents or incidents occurred, learning was identified to reduce the risk of them happening again.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This service was registered with us under this new provider on 26 March 2019, and this is the first inspection.

Why we inspected

This was a planned inspection in line with our inspection programme. We have made changes to the way we work due to COVID-19. This is to avoid putting pressure on services that are caring for people. We completed a focussed inspection. During this inspection we looked at two key areas, safe and well-led. We do not look at all the five key questions during a focussed inspection. Therefore, the service was not given an overall 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.