St Thomas Complex

Updated 23 August 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

The inspection was carried out by 1 inspector and 1 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 Thomas Complex 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 Thomas Complex 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.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 20 July 2023 and ended on 20 July 2023. We visited the service on 20 July 2023.

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

During the inspection we spoke with 7 people and 3 relatives about their experience of the care provided. We spoke with 10 members of staff including the registered manager, deputy manager, 5 support workers including 1 senior support worker, the activities coordinator, 1 domestic and 1 kitchen assistant.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 3 people’s care records and multiple medicines records. We looked at 3 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including training information and policies and procedures were reviewed.

Updated 23 August 2023

About the service

St Thomas Complex is a care home providing accommodation and personal care to up to 52 people. The service provides support to older people including people who live with a dementia. At the time of our inspection there were 29 people using the service.

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

There were sufficient staff to support people safely. We have made a recommendation about ensuring staffing levels and staff deployment are kept under review on the lower ground floor of the home to ensure people are kept engaged and stimulated if they wish.

Staff had received safeguarding training and were clear on how and when to raise their concerns. Where appropriate, actions were taken to keep people safe. Staff contacted health professionals when people’s health needs changed.

Staff followed effective processes to assess and provide the support people needed to take their medicines safely. We have made a recommendation about protocols for the use of ‘when required’ medicines, where prescribed.

People and relatives were very complimentary about the care provided by staff. They trusted the staff who supported them. They said staff were kind, caring and supportive of people and their families. Their comments included, “I can’t recommend the place enough, I was rock bottom before [Name] came in, it is a God send”, and “Staff are lovely, they are so lovely and friendly. They have time to talk with me.”

Staff followed good infection control practices. A programme of refurbishment was taking place around the home.

Records provided guidance to ensure people received safe, person-centred care and support from all staff members. Staff spoke very positively about working at the home and the people they cared for. They said communication was effective to ensure they were kept up-to-date about any changes in people’s care and support 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.

A quality assurance system was in place, to assess the standards of care in the service. We have made a recommendation regarding the external governance of the service.

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 9 March 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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 remained good based on the findings of this inspection.

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

Recommendations

We have made a recommendation to keep staffing levels and staff deployment under review on the lower ground floor.

We have made a recommendation about the management of some medicines.

We have made a recommendation that regular visits to the service by the provider, or their representative should resume, to provide external checks of the service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.