Archived: St George's Care Home

We considered all the evidence we had gathered under the outcomes we inspected for this follow up inspection. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

If you want to see the evidence supporting our summary please read the full report. This is a summary of what we found '

Is the service safe?

The acting manager set the staff rotas. Records showed that the acting manager had not taken people's care needs into account when making decisions about the number of staff the service required. There were gaps in staffing numbers at specific times of the day and at weekends. Comments from staff included, 'We have tried to have three staff on but there is just not enough of us', 'We need more staff; it's a concern not having three staff on ' tea time is the main issue' and 'We have not been able to go in twos (as agreed by the acting manager) because there is no-one left to see to the other service users.'

People in charge of shifts were not fully aware of safeguarding procedures. This meant that if incidents occurred they would be unsure of how to safeguard vulnerable people who used the service.

Is the service effective?

A care plan and risk management plan had not been completed for one person who used the service. This meant that staff may not have full guidance in how to support the person.

Is the service caring?

We observed staff spoke with people and interacted with them in a kind and patient way. They gave people time to respond to questions and they listened to what they had to say.

Staff had purchased food items out of their own monies and waited to be reimbursed.

Senior care staff told us that recent changes to the staff rota were agreed reluctantly by them, as they did not want to 'let down' the people who used the service. They were completing additional roles until a new manager was appointed on a permanent basis.

Is the service responsive?

The registered provider has been slow to respond to concerns raised in Care Quality Commission inspection reports and also reports from other regulators. This meant there had been delays in addressing shortfalls and could compromise the safety and wellbeing of people who used the service.

Is the service well-led?

The service has had several managers in the last few months. This has led to instability in the way the service is managed.

The registered provider did not have an effective quality assurance system in place that consisted of audits and action plans to rectify shortfalls. This meant that the quality of the service provided to people was not monitored and shortfalls in systems were not identified.

The food order was late in being authorised by the registered provider, which meant the service ran out of specific items. Comments from staff included, 'We ran out of sugar on Saturday and on Tuesday we ran out of bread and milk' and 'The food order was authorised last night and is due today.' The food order arrived during the inspection visit on 29 August 2014. The registered provider has assured us this will be managed more effectively and petty cash will be available for use in emergencies.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with relatives and people who used the service and speaking with staff. We also looked at records. If you want to see the evidence supporting our summary please read the full report.

We are considering our regulatory response to these inspection findings.

Is the service safe?

People who used the service were treated with dignity and respect by the staff.

Safeguarding procedures were not robust and we found some incidents of concern had not been reported to the local authority safeguarding team or to the Care Quality Commission.

We found there were concerns with the environment, the equipment used in the service and with cleanliness. For example, there were no window restrictors in the upstairs bedroom windows, a hoist had not been checked by a competent person, not all hot water outlets had a safe temperature and a bed rail was unsafe. A local authority health and safety officer is following these up.

The provider did not follow best practice guidance in relation to infection prevention and control (IPC). A specialist nurse in IPC is following these issues up. Some carpets and chairs in the sitting rooms and bedrooms were stained, a mattress and bed base were badly stained, there were damp patches in some communal areas and there was an excessive amount of bird droppings on windows that were open due to the heat.

The service did not have robust staff recruitment systems in place. This meant we were unsure if all the staff who worked in the service had been checked and passed as safe to work with vulnerable adults.

There were not sufficient numbers of staff on duty to support people's individual needs and promote their independence.

Is the service effective?

Not all people had assessments of their needs and had care delivered in line with their care plans. This meant we could not be sure people had all their care needs met. People who used the service and their relatives had not always been involved in writing plans of care. Although care plans were evaluated they were not always updated appropriately.

There were limited activities for people to participate in which meant there was a risk they could lack choice, be under-stimulated and be bored.

Some of the furniture and equipment used in the service was in need of replacement.

Is the service caring?

People told us staff who supported them were kind and attentive. We saw that staff showed encouragement and patience when supporting people. All interactions between staff and people who used the service were positive.

Is the service responsive?

People had access to a range of health and social care professionals such as GPs, district nurses, dieticians, occupational therapists, opticians and chiropodists. There was evidence the staff team sought appropriate advice, support and guidance during emergency situations.

There had been suggestions and comments made in surveys about the lack of activities, the d'cor and insufficient staff but these had not been addressed.

People who used the service told us they felt able to complain. A relative told us their complaint was not dealt with satisfactorily.

Is the service well-led?

There was no consistent quality assurance system in place to assess if the home was operating correctly. We saw no action plans were in place to address any shortfalls and monitor that progress was made to address them.

The Care Quality Commission had not received notifications of incidents that affected the wellbeing of people who used the service. This was required by specific regulations so we could monitor how the service managed the incidents.

We had concerns about the financial viability of the service. The general environment, internally and externally, and lack of maintenance, redecoration, repair and replacement of furniture and equipment led us to believe there was a concern with the availability of finances. This was added to concerns about staffing, management of the service including the payment of bills and wages and delays in obtaining public liability insurance. We have asked the provider to send us financial information so we can check this out but we have not received all the information we require so far.

We observed the new manager to be approachable and people who used the service and their relatives spoke highly of them.

Staff told us they were well supported by the new manager and some staff had received supervision meetings to discuss their progress.

What people who used the service and those that matter to them said about the care and support they received: -

Regarding activities, 'They are trying to organise things, the manager will get it going, I know she will',

Regarding the staff team and staffing levels, 'The girls are wonderful, I can't fault them', 'They will see to anything you require', 'The staff are alright; I'm very satisfied', 'There are two staff, sometimes three. When there are three on there is no problem getting a bath. Today I should have had one but I didn't get one', 'There is always someone around; they come as quick as they can ' they know you don't call for nothing", 'They would get help quickly for you', 'I have a bath whenever I want; I just tell them and they'll take me' and 'Staff encourage you to do as much as you can for yourself.'

A relative told us, 'She was put on a commode and has in the past been left for a while" and 'They take a long time to answer the phone at night.'

Regarding the environment, 'I don't use the conservatory; I've been in it twice but it gets very hot and I can't stand the heat' and 'The d'cor is adequate ' lots need doing.'

Regarding management of the service, 'Yes I would definitely complain; it would have to be something that upset me. I asked them who I had to complain to when I came in here and they said a senior or the boss', 'The managers are very good' and 'If I had to complain I would; yes they would sort it.'

A relative told us, 'There have been issues in the past with heating, water and bread (supplies)' and 'It wasn't well-led but I think it is getting better. It all changed when the last manager started and it felt better.'

Comments from surveys the service undertook in March 2014 included: -

'Members of staff are very good', 'The care she has received has been second to none' and 'No problems with any member of staff.' However, comments were not so positive about the environment and staffing numbers. For example, 'Not enough staff', 'D'cor could be better', "Things need to improve by the owners', 'It's in need of a good clean and decoration', 'The home needs a bit of TLC', 'It needs decorating badly' and 'Home looks neglected.'

The inspection team consisted of two inspectors who gathered evidence against the outcomes inspected to help answer our five key questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read our full report.

Is the service safe? :-

People who used the service told us they felt safe and trusted the staff. They told us that staff listened to them to ensure their dignity was promoted and their rights were respected.

Staff responsible administering medication had a good understanding of their role and provided with training on this to ensure people who used the service were kept safe from harm.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. An external trainer confirmed staff were able to provide them with a good understanding about this and when an application should be made to ensure people's human rights were protected. This helped ensure people who used the service are safeguarded from avoidable harm.

Whilst we saw there had been some negative feedback from people's relatives about the general standard of d'cor of the building, we found a member of maintenance staff had now been appointed to ensure the building and environment was kept safe for people to use.

Whilst policies and procedures were available to make sure unsafe practice was identified and people protected, we saw evidence these had not always been followed and expert advice not obtained in a timely manner. We saw that actions prescribed by the fire service had not been implemented in the timescales given. We gained support from the fire service about this whilst we were present, to ensure people who used the service and others were not placed at potential risk to their health safety and welfare.

We found there were times when there were only two care staff on duty, despite there being two people who used the service who required two staff to safely move them. The provider had previously agreed to ensure there would be three members care staff available during the day.

We also found on one of our visits a lack of hot water available, which meant that staff consequently had to carry kettles and buckets of boiled water to people's rooms, which posed a potential risk to the health, safety and welfare of both staff and people who used the service.

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Is the service effective? :-

People and their relatives told us that staff involved them in the development of plans of support for them were consulted about their assessment of their health and care needs. People and their relatives told us that care plans were reviewed to reflect their changing needs. We saw that a programme of training had been implemented to ensure staff had the right skills to safely carry out their roles.

Is the service caring? :-

People who used the service told us that staff were, 'Very good and friendly.'

Visiting relatives told us they had, 'No problems with the staff.' One relative told us they visited on a weekly basis. They told us their member of family had been supported in bed for a number of years and that they were, 'Comfortable and well looked after' The relative told us, 'Staff are fantastic. '

We observed staff demonstrated sensitivity and compassion for people who used the service. When speaking with staff it was clear they had a genuine concern and empathy for the promotion of people's health, safety and welfare.

We saw evidence that people's preferences, interests, and individual needs were recorded and that care and support was provided in accordance with their wishes and feelings.

Is the service responsive? :-

The local authority told us about a meeting with families that had highlighted frustration with the provider's lack of response in regards to addressing complaints and concerns. This meant we could not be assured there was an effective system to ensure people's complaints would be acted on to enable the service to improve.

Whilst we saw relative feedback in recent surveys that commented very positively about the staff, we saw concerns about staffing levels and overall stability of management support had also been raised. One comment in a recent relative quality survey stated, 'Things need to improve by the owners."

We saw recent feedback from people and their relatives about the quality of care provision that contained a variety of mixed comments. One person had stated, 'The care received was second to none.' However we also saw a relative comment that stated, 'We would have gone elsewhere, if we had gone on first impressions.'

Is the service well-led? :-

The service had appointed a new acting manager since our last visit, who told us they had begun the process of registration with the Care Quality Commission to run the home. The acting manager had improved the standard of record keeping and developed the staff files to enable potential issues to be identified and opportunities provided to change things for the better. We saw a new quality assurance system had been obtained and was in the process of being implemented to enable the service to be monitored. The acting manager however told us they had not yet developed an action plan in respect of findings from audits for this, due to other priorities in the home. This meant systems were not yet able to effectively demonstrate and identify any learning or analysis of the information obtained.

There was uncertainty about the provider's arrangements to support the acting manager to effectively run the service. We found that arrangements to respond to requests from the acting manager for resources were not sufficiently developed to enable essential standards of quality and safety to be safely met and sustained.

We wrote to the provider to request an action plan following our last visit on 10 December 2013 on two occasions, about how they were going to address the compliance action we reissued. This was to ensure the service had quality checking systems in place to manage risks and assure the health, welfare and safety of people who used the service. The provider failed to respond to our requests however, which is a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We looked at the stocks of food and observed adequate supplies were available at the time of our visit. We saw this included supplies of milk and bread and that freezer and fridges were appropriately stocked with additional access to satisfactory amounts of dried and tinned goods. We found that people were provided with a choice of nutritious home cooked meals.

There was evidence in people's care records of their food preferences and individual likes and dislikes. We saw people's weight was regularly monitored and nutritional needs were assessed, to ensure risks of malnourishment and dehydration were addressed. People told us they enjoyed the food and were able to order alternatives, if they did not want what was on offer. People's comments about the food included, 'You just can't fault it' and 'We have a marvellous cook who does her best.'

We found that staff were not appropriately supported in relation to their responsibilities, to enable them to deliver care and treatment to people safely and to an appropriate standard. We found there were significant shortfalls in essential staff training, much of which had not been refreshed since 2012. Whilst there was evidence of staff places recently booked on a variety of free training, we saw this did not include moving and handling training, first aid or fire safety. Shortfalls in staff training meant staff may not have the skills needed to safely carry out their role.

We found there were two people who required two staff to move them safely. We were told there was currently no formal structured induction programme in place and that a new member of staff had not received training in moving and handling since commencing employment or judged competent in the safe use the hoist. This meant there were potential risks to people's health, safety and welfare. We spoke to the local authority about this and agreed make a safeguarding alert to ensure people were protected from harm.

Minutes of a meeting held with people on 13 January 2014 contained evidence of concerns about availability of staff. We saw a person had stated this had resulted on "More than one occasion" of a toileting and soiling accident. We saw the person had commented this was, "Down to the levels of staff and not the carers fault." Staff told us the levels of staffing provision sometimes impacted on their ability to effectively meet people's needs. They said this was a particular issue at busy times, or when professionals such as district nurses, GP's or social workers were visiting.

We spoke with the two staff on duty who told us they had not received supervision to enable the acting manager to monitor their performance. We saw however that since our last visit the acting manager had begun to implement a programme for this, with two of the sixteen staff team recorded so far as having received this.

The provider did not have an effective system to regularly assess and monitor the quality of service that people received. There was a quality assurance system in place that covered a wide range of elements of the service. The acting manager indicated however they had not had time to complete this to enable assurance to be gained and areas for improvement to be highlighted. Whilst there was evidence in people's care records their health, safety and welfare was monitored, we found associated management audits to identify risks in relation to this had not been completed.

There was evidence the service had not learnt from previous incidents, to ensure potential risks to people were identified and effectively addressed. We were told about uncertainties concerning access to funds to support the effective running of the home. We were told a credit card had been issued to the acting manager to cover emergency situations and contingencies. The acting manager however told us they had not been issued with a 'pin number' for this, to enable them to access the available resources. The acting manager told us they were also uncertain about how much money was available on the card. We saw that financial records were poorly maintained and there was uncertainty about when petty cash was reimbursed. We checked the petty cash tin in the safe and found evidence of staff receipts for supplies they had bought in themselves, together with one penny.

We found there was currently no member of maintenance staff employed to ensure the building and equipment was kept safe for people to use. We observed a number of light bulbs in need of replacement that posed a potential risk to people's health, safety and welfare. Whilst there was evidence of completed audits of housekeeping and the general environment in the home, we found that management audits regarding the quality of client rooms and building had not been undertaken, despite known shortfalls in this area.

One person who used the service told us, 'It's a lovely home, but there needs a lot doing to it' whilst staff told us, 'We do the best we can with what we've got.'

We observed staff providing individual time with people, offering choices about their support. We saw this was carried out in an open and caring manner with staff providing opportunities to people to ensure their dignity was respected.

People told us they were happy with the service received and were comfortable and had no concerns about the service. Two visiting relatives told us they were satisfied with the quality of the service. One told us, 'Mum has been here for a lot of years'.she is well cared for.' The other said, 'It's a happy place'my dad was very thin when he came in but he is wonderful now'He says the staff are wonderful.'

We found individual case records for people had been updated and amended since our last visit. This ensured the records contained relevant information to enable staff to support and enable people's safety to be appropriately promoted.

We saw up to date records were maintained of temperature checks of the water system. We found that action had been taken to ensure staff were familiar with their health and safety responsibilities. We found there was evidence of investment in the service since the last time we visited and that a worn carpet had been replaced and new bedding obtained.

We found enough staff were available to meet people's needs. Staff told us they felt the new acting manager listened to them and that they were well supported and provided with clear direction to help them carry out their roles.

We saw a system had been developed to identify, assess and manage risks to people who used the service. However we found this had not yet been implemented which meant people's health, safety and welfare may not be fully protected.

We found people's records were accurate and securely kept to ensure their confidentiality was maintained.

Information about people's basic needs was available to enable staff to support them and ensure they were kept safe from harm. However, we found that people's care records were not personalised to ensure their individual needs could be fully met. Generic risk assessments had been carried out to ensure people were safeguarded from harm; however these had not been regularly reviewed or contained details about how these should be managed by staff.

A member of staff from the local health authority had visited the home to ensure people were protected from the risks of infection. We saw evidence of overall good progress with implementing an action plan that they had provided.

We found the provider had commissioned improvements to the building to ensure people who used the service lived. However, we also saw further deterioration in some other areas and we could not be sure people who used the service lived in a safe environment and were kept safe from harm.

We found that staff morale was low, due to uncertainties about how they were expected to perform their roles and ensure they were able to safely meet people's needs. A member of staff with specialist health needs told us, 'When a resident needs regular turning. I sometimes have to refuse them, as there are only two staff on duty and I can't do it.'

We were unable to find evidence of systematic management checks, to ensure the health safety and welfare of people who used the service was effectively monitored by the service. Quality checks to monitor the performance of the service were not adequately maintained, this meant that risks to people who used the service were not effectively analysed and addressed.

We found that people were not fully protected from the risk of infection because appropriate guidance had not been followed. We observed a quantity of dirty clothing that had been left on the floor in the clean area of the laundry and hoist slings that were left in communal areas of the home, which posed a potential risk to people from cross infection.

We found that arrangements were in place in relation to obtaining and recording of medicines and that these were kept safely or disposed of appropriately.

We found that whilst the provider had taken steps to provide care in an environment that was safe for people to use, they were not fully protected against risks due to failures to ensure the operation of the premises were adequately maintained.

We saw that arrangements were in place to ensure staff were properly recruited and that checks had been carried out to ensure they were safe to work with people who used the service.

People told us that staff supported them well and responded to requests for assistance appropriately. People told us that staff answered call bells when required and we observed staff responding to these in an efficient and professional manner.

Comments from people about staff included, 'The Girls are very good', and 'They are all very kind and caring.' A visiting relative told us their member of family had made 'Good progress' since they had moved into the home. People told us they enjoyed their meals and that there were always' Plenty of choices and alternatives' of food

We observed staff following infection control procedures and found adequate supplies of protective equipment; including disposable aprons, gloves, paper towels and hand gel dispensers.

People told us they were 'Comfortable' in the home. We saw a joiner making adjustments to the building to ensure it was safely maintained. We saw progress with implementing a schedule of work that was needed by an approved electrical contractor.

We found a lack of accurate recording and stock control of medication kept in the home. We saw that staff files were inconsistently organised and lacked documentation of checks to confirm safe recruitment procedures had been followed. We made compliance actions about this.