6 July 2022
During an inspection looking at part of the service
St Andrew's Nursing and Care Home is situated in Ewerby near Sleaford, providing accommodation for people who require residential and nursing care. The service can support up to 45 older and younger adults, some of whom may experience memory loss. There were 33 people living in the service at the time of inspection.
People’s experience of using this service and what we found
There were quality assurance processes in place. However, audits continued to be ineffective and had not identified shortfalls in the service.
People’s care records were not always accurate or effective in order to give staff guidance on how to meet the nutritional needs of people.
People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Systems and processes around safe recruitment needed improvement. Checks had not consistently been carried out in respect of some staff’s right to work in the UK. The provider had not always assured themselves of gaps in employment and had not always ensured references were sought from staff’s last employer when staff were recruited by a recruitment agency.
Medicines management at the service had improved. There was guidance for staff to follow on how to safely administer “As and when medicines.” However, the service would benefit from improvements in the recording of medicated creams.
There had been an inconsistency in management at the service since the last inspection. Managers at the service have been interim, with no registered manager since August 2021.
Staff had received training in order to recognise how to protect people from abuse. People and their families told us they felt safe at 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 and update
The last rating for this service was requires improvement (published 09 August 2021) and there were breaches of regulation 12 and 17. CQC issued the provider with a warning notice in relation to Regulation 17 (Good governance).
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 the provider remained in breach of regulation 17 (Good governance.)
Why we inspected
We carried out an unannounced focused inspection of this service on 27 May 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 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 and Well-led which contain those requirements.
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.
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 remains 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 Andrew's Nursing and Care Home on our website at www.cqc.org.uk.
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 monitor the service and will take further action if needed.
We have identified breaches in relation to the safety of people's care and good governance at the service.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will 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.