St Teresa's Nursing Home

Updated 13 July 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 team was made up of 2 inspectors 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 Teresa’s Nursing 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 Teresa’s Nursing Home 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 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.

What we did before inspection

We reviewed information we had received about the service since the last inspection. 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 10 people, 5 relatives and 11 staff including the registered manager, registered nurses and care staff. We spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We reviewed various records in relation to the running of the service including care plans, medicines records, maintenance checks and quality audits. 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.

Updated 13 July 2023

About the service

St Teresa’s Nursing Home is a residential care home providing regulated activities accommodation for persons requiring nursing or personal care and treatment of disease, disorder or injury to up to 70 people. The service provides support to older people and people with dementia. At the time of our inspection there were 60 people using the service.

St Teresa’s incorporates a former nunnery with more modern, purpose built accommodation that is separated into 2 wings: Gainsborough and Bartelt. The service is laid out over 3 floors, bedrooms can be found on each floor, with some offering en-suite facilities. People have access to communal dining and lounging areas, including a recently installed sensory space. There is level access to large, well-stocked gardens and the registered manager’s office is located adjacent to the reception area.

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

Staff spoke confidently about protecting people from the risk of abuse. There were sufficient numbers of staff to keep people safe and staff received training relevant to people’s needs. Risk assessments were in place and provided guidance for staff. Infection prevention and control measures were implemented, and the service was visibly clean throughout. Overall, medicines were managed safely. In response to our feedback, the provider did implement additional cold storage for medicines and brought forward a planned meeting with an air conditioning technician, with the view of air conditioned medicines storage rooms.

We observed staff being kind and caring to people. People’s equality characteristics were respected, and different cultures were embraced. We observed staff maintaining people’s privacy by knocking on their doors prior to entering.

People were supported to eat and drink sufficiently; the dining experience had improved since our previous inspection. The layout of the premises had been reconfigured to aid the flow of care delivery. People were supported to access healthcare and professionals spoke positively about working with staff. We found people’s support with oral healthcare was inconsistent. The provider responded to our concerns and implemented a dental tracker at the time of our inspection. We did not find people experienced poor outcomes in relation to these inconsistencies. We received mixed comments from people about how consistently staff delivered care to support people’s choices.

People and relatives spoke positively about the registered manager and said they could raise concerns if needed. The provider continued to build relationships with local organisations and volunteers. Statutory notifications were submitted to CQC in line with regulations. Overall, audits and checks were used effectively to identify shortfalls, however we did find gaps in documentation that had not been identified by the provider checks.

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 requires improvement (published 6 November 2020) and there were breaches of regulation. 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.

Why we inspected

We inspected this service in line with current CQC priorities because the provider told us they had made significant improvements to care provision.

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.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. The overall rating for the service has changed from requires improvement to 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 Teresa’s Nursing Home on our website at www.cqc.org.uk.

Recommendations

We have made one recommendation in relation to the consistency of governance systems.

Follow up

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