CQC report explained · a residential care home, run by Welford Healthcare
St Peter's House
29 Out Risbygate, Bury St Edmunds, IP33 3RJ
Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Requires Improvement; inspectors found unmanaged risks, medicines and staffing shortfalls, and weak oversight at St Peter's House.
This was an unannounced focused inspection on 13 and 27 July 2023. Inspectors spoke with people, relatives and staff, reviewed care and medicine records, and checked how the home was managed.
They found that risks were not always properly assessed or managed. Medicines were not always given or recorded safely. There were concerns about delays in answering call bells, people’s basic care needs, food and fluid records, and referrals after falls.
The home’s systems for checking quality were not effective enough to find and fix these problems. The overall rating changed from Good at the previous inspection, published on 24 May 2022, to Requires Improvement. Only Safe and Well-led were inspected in this visit. The other ratings carried over from the previous inspection.
Safeguarding knowledge
Staff had training and understood how to identify and report safeguarding concerns.
“Staff had been trained to safeguard people from abuse and understood when and how to report safeguarding concerns to the appropriate authority.” from the report
Safe recruitment
The home completed references and criminal record checks before staff were employed.
“People were supported by staff who had been recruited safely.” from the report
Infection control
Inspectors were assured about the home’s infection prevention measures, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Open response
The provider accepted the findings and acted during and after the inspection.
“The provider demonstrated an open and transparent approach and understood their responsibilities under the duty of candour.” from the report
Unmanaged risks
seriousRisk assessments did not contain enough guidance for staff. Inspectors also found an unsecured wardrobe and gaps in food, fluid and oral care records.
“Risks had not been sufficiently assessed. Risk assessments were missing detailed guidance for staff on how to reduce risks.” from the report
Medicine safety
seriousSome medicines were unclear, unsecured or not recorded consistently. There were also concerns about missed medicines, creams and medicines given when people refused them.
“Although we found no evidence that people had been harmed, the safe management of medicines was not always effective.” from the report
Weak quality checks
seriousAudits and governance systems did not identify or resolve important problems. Records were not always complete or accurate.
“The provider had failed to assess, monitor, and improve the service.” from the report
Management culture
needs fixingMany people, relatives and staff described a difficult atmosphere and ineffective management arrangements. The provider said it took immediate action to review these arrangements.
“We received overwhelmingly strong feedback that the management arrangements at the home were not effective or conducive to a professional working relationship.” from the report
- 01What specific changes have been made to risk assessments, especially for people at risk of falls or taking anticoagulant medicines?
- 02How are missed, refused and as-required medicines now recorded and followed up?
- 03How many staff are deployed on each floor and shift, and how are call bell response times checked?
- 04What has changed in the quality audits, and how do you make sure actions are completed?
- 05What is the current management arrangement following the registered manager leaving shortly after the inspection?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 7 September 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St Peter's House
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Gooddown from OutstandingSafe: GoodWell-led: Good
- November 2017Outstandingup from GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Good
- September 2015GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- December 2020
Registered with the Care Quality Commission on 11 December 2020.
Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.
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