26 July 2022
During an inspection looking at part of 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.