St Peter's House

Updated 7 September 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken by 2 inspectors, a pharmacist inspector, and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

St Peter’s Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Peter’s Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post, however, they left employment shortly after our inspection visit. The provider put in place a temporary manager whilst permanent recruitment took place.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 13 people who used the service and 7 relatives about their experience of the care provided. We spoke with the registered manager, deputy manager, business support manager, regional manager, kitchen staff, housekeeping staff and 7 care staff during our inspection visit.

Following the visit, we had email or telephone correspondence with a further 16 relatives and 12 staff members.

We reviewed a range of records. This included 6 people's care records, multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision. We reviewed records relating to the management of the service including quality assurance monitoring and the services policies and procedures.

Updated 7 September 2023

About the service

St Peter's House is a residential care home providing the regulated activity of accommodation for person's who require nursing or personal care for up to 66 people. The service does not provide nursing care. The service provides support to older people some of whom lived with dementia. At the time of our inspection there were 45 people using the service.

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

We were not assured the systems, processes, and leadership currently in place to oversee the quality assurance of the service were robust and effective and regulatory requirements were not always being met. We received mixed feedback from people and their relatives about the standards of care and support provided.

People were not consistently protected against harm because all risks to their safety had not been identified and managed.

Medicines were not always safely managed and audits in place to monitor the safety of medicines were not effective in keeping people safe.

There was a lack of consistent and effective leadership at the service and quality assurance systems were not effective in identifying and addressing issues.

The provider took responsibility for the issues we found and responded immediately after the inspection to make improvements that were required.

Staff had been trained to safeguard people from abuse and understood when and how to report safeguarding concerns to the appropriate authority. Recruitment and criminal records checks were undertaken on staff to make sure they were suitable to support people.

Staff had access to personal protective equipment (PPE) and there were effective infection prevention control measures in place.

People were mainly supported to have maximum choice and control of their lives and staff mainly supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 24 May 2022)

Why we inspected

We received concerns in relation to the quality of people’s personal care and the high number of falls people were having. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report.

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 good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We have identified breaches in relation to the safe management of risk and medicines as well as the staffing levels and the providers governance at this inspection. Please see the action we have told the provider to take at the end of this report.

We will request an action plan from the provider and will also meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.