St Josephs Nursing Home

Updated 6 September 2022

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

The inspection was undertaken by one inspector.

Service and service type

St Josephs 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 Josephs is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

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 and professionals who work with the service. 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 five people who used the service and three relatives about their experience of the care provided. We spoke with six members of staff including the registered manager, care workers and the chef.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 6 September 2022

About the service

St Josephs is a nursing home providing regulated activities accommodation for persons who require nursing or personal care and treatment of disease, disorder or injury to up to 24 people. The service provides support to people who have a range of care and nursing needs including Parkinson’s disease, frailty of age, diabetes and people living with dementia. At the time of our inspection there were 22 people using the service.

St Joseph’s accommodates 24 people over two floors in one adapted building. The care home is attached to a convent and people have direct access to a shared chapel.

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

Quality assurance processes failed to have identified the concerns found at inspection in relation to fire safety. Record keeping of paper documents was disorganised and some records of health and safety checks were missing.

Electronic care planning and risk management had recently been introduced and needed time to become embedded within the day to day running of the service. Care plans and risk management processes were current and up to date. Information provided enough guidance to ensure people's needs were met and risks were mitigated.

Safe recruitment systems and processes were in place. A formal induction was being developed by the provider. Training was provided for staff to ensure they could carry out their role safely and effectively. People told us they felt safe. Staff had received safeguarding training and were able to demonstrate their understanding and responsibilities to reduce the risk of harm to people.

Peoples nutritional needs were met. People who required specialist diets or additional support had their needs met. Mealtime experiences were positive people told us they had plenty to eat.

People and staff provided positive feedback on the management of the service. People were treated with kindness and compassion and staff were friendly and respectful. People and their relatives told us they were happy with the service they received. Staffing levels were enough to meet people’s individual needs.

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.

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

The last rating for this service was inadequate (published 9 March 2022) and there were breaches of regulations. 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.

This service has been in Special Measures since 23 March 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

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.

We carried out an unannounced focused inspection of this service on 21 October 2021(published 9 March 2022). 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, safeguarding service users from abuse and improper treatment, fit and proper persons employed, need for 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 inadequate to requires improvement. 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 Josephs on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to 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.