We carried out a review of the data available to us about St Andrew's Court 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 Andrew's Court, you can give feedback on this service.
St Andrew's Court is a residential care home that provides accommodation, nursing and personal care to a maximum of 20 people, including people living with dementia, physical disability and people with a mental health diagnosis. Eighteen people were living in the home on day one of the inspection and fifteen on day two.
The main part of the home contains 18 single occupancy bedrooms over two floors. Adjoining the main building is a two story two-bedroom house providing accommodation for two people. This self-contained house has its own private access independent from the main home.
People’s experience of using this service and what we found
Records were not always completed effectively. A system was in place to monitor the quality and safety of the service.
The safety of the service was maintained through regular checks.
Medicine practices were in line with best practice guidelines and staff received training to meet people's individual assessed needs.
People and staff spoke positively about the management of the service. There was a positive, caring culture within the service and we observed people were treated with dignity and respect.
People were happy with the care they received, they felt safe and well looked after. Care plans included risk assessments for known risks and staff followed support plans to help keep people safe. Care plans and risk assessments were up to date and regularly reviewed.
People were regularly asked their views on the service provided and action had been taken when suggestions were made.
The provider and staff worked in partnership with other health and social care agencies to deliver good outcomes for people and to ensure their needs were met and reviewed.
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.
The home was clean and tidy. Staff had access to and followed clear policies and procedures on infection, prevention and control that met current and relevant national guidance.
For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 22 January 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we recommended the provider works in line with the principles of The Mental Capacity Act 2005 to ensure robust mental capacity assessments are in place and include multidisciplinary involvement. At this inspection we found the provider had acted on this recommendation and improvements had been made.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 2 and 8 December 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, consent and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe, effective and well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Andrews Court on our website at www.cqc.org.uk.
Recommendations
We have made a recommendation in relation to good governance.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The main part of the home contains 18 single occupancy bedrooms over two floors. Adjoining the main building is a two story two-bedroom house providing accommodation for two people. This self-contained house has its own private access independent from the main home.
People’s experience of using this service and what we found
A system was in place to monitor the quality and safety of the service, however these were not always effective in identifying and addressing issues.
Analysis of falls and incidents were not always completed to reduce the risk of reoccurrence and to learn lessons. Risks associated with fire safety had not been addressed with measures to reduce the risk of harm.
There were shortfalls in training to enable staff to carry out their roles effectively.
Medicine practices were not always in line with best practice guidelines.
People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.
We have made a recommendation in relation to the principles of the Mental Capacity Act 2005.
The provider had systems in place to safeguard people from abuse and staff demonstrated an awareness of safety and how to minimise risks.
People were happy with the care they received, they felt safe and well looked after. Staff had been recruited safely and there were enough staff on duty.
The home was clean and tidy and additional cleaning ensured people were safe from the risk of infection.
Care plans were up to date, risk assessments were in place and regularly reviewed.
Staff had positive links with healthcare professionals which promoted people's wellbeing.
People were regularly asked their views on the service provided and action had been taken when suggestions were made.
For more details, please see the full report which is on the Care Quality Commission's (CQC) website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 23 October 2019 and this was their first inspection.
Why we inspected
This was a planned comprehensive inspection.
We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.
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.
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This included a breach of regulation 12 (safe care and treatment), regulation 18 (staffing), and regulation 17 (good governance).
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 for 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.