St Georges Court Care Home

St Georges Court Care Home is a ‘care home’ providing personal and nursing care to up to 76 older people. At the time of our inspection there were 67 people using the service, some of whom were living with dementia. The service has 3 floors and has its own adapted facilities and shared areas for people to use.

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

The provider’s quality monitoring systems had failed to identify that safeguarding processes were not always followed by staff to keep people safe from poor care. Staff had training but they did not always have the skills and knowledge to promote people’s nursing needs, health and well-being. Risks to people were not always considered. People’s care plans and risk assessments were not updated quickly enough when there were changes in people’s needs, nor did they always contain enough information to guide staff to support people effectively and safely.

Checks for medical devices were not always being completed in line with the manufacturer's directions. Medicines were not always managed safely, and people’s privacy and dignity was not always promoted by staff. Lessons were not always learnt. Internal investigations into incidents and accidents failed to identify outcomes, actions and learning to help reduce the risk of harm to people’s well-being.

Clinical areas within the service were not always kept clean to promote good infection control practices. Areas of flooring throughout the service were cracked and damaged. This included the laundry room. This meant that the cleaning of these areas to promote good infection control would be more difficult. The layout of furniture and furnishings of the floor that housed people, including people with complex dementia and nursing needs, was not conducive to supporting people who may be noise sensitive. The registered manager told us they wanted to put specialist signage in the service. This would help people who were sensory impaired or were living with dementia find it easier to orientate themselves around the building.

The provider’s governance, systems and audit processes were not robust enough. This was recognised by the provider's senior leadership team who told us they were committed to making and sustaining ongoing improvements required. The registered manager and the provider’s senior leadership team were responsive to our feedback and engaged with the CQC inspection team fully during the inspection process.

Despite our inspection findings people and their relatives told us they and their family member felt safe at the service. Whilst we observed missed opportunities for staff to meaningfully engage with people, we also saw some kind and considered interactions.

People's needs were assessed prior to them moving into the service. However, people, and their relatives, gave mixed feedback for their involvement in the care planning process. Activities happened at the service, however people living with dementia were not always given enough stimulation to help them spend their day meaningfully. Staff reacted to people’s anxieties rather than being proactive to try to reduce the number of incidents that occurred.

People, and their relatives told us they knew how to raise a complaint. However, verbal complaints were not always formally documented by staff.

The provider undertook safe recruitment procedures. Staff supported people in the main to receive a balanced diet and have enough to drink. However, people’s care records contained conflicting information to guide staff. People and their relatives had mixed opinions on whether they were involved in care decisions and reviews.

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.

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 (report published 16 December 2017).

Why we inspected

The inspection was prompted in part due to concerns received by the CQC about safe care and treatment, safeguarding, infection prevention and control, promoting dignity, safe medicines management, and good governance.

We found evidence during this inspection that people were at risk of harm from these concerns. Please see the safe, effective, caring, responsive and well-led sections of this full report.

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.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people from abuse, person-centred care, suitably skilled staff, promoting people’s dignity and respect, safe care and treatment, premises and equipment, and good governance at this inspection.

We wrote to the provider during our inspection due to our extensive concerns of people receiving poor quality care. The provider told us they had not been aware of the significant failings at the service and risks posed to people's safety and well-being. The provider submitted a robust action plan to the CQC in response to those concerns.

We have made a recommendation for the provider to review the accessible information available for people. We have also recommended the provider reviews the UK resuscitation council guidelines regarding end of life care information to guide staff.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

Staff made sure that people were protected against the transmission of infection from visitors by scheduling visits, limiting areas that visitors could access and being available to escort visitors.

Staff put appropriate actions into place to make sure people were admitted safely into the service.

Staff had enough personal protective equipment, such as masks, gloves and aprons, and had supported people so that they also understood the need for this.

Regular COVID-19 testing was carried out to make sure people and staff were safe.

The home was clean and staff had increased cleaning of frequently touched surfaces to reduce the risk of transmission of infection.

The provider made sure staff and the registered manager received enough support during the pandemic and when additional staff were needed.

There was COVID-19 specific policies and plans, which meant staff were guided to take appropriate actions to reduce the risk of transmission.

At the last inspection, the service was rated Good. At this inspection we found the service remained Good.

There was a registered manager in post at the time of our visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff knew how to respond to possible abuse and how to reduce risks to people. There were enough staff who had been recruited properly to make sure they were suitable to work with people. Medicines were stored and administered safely.

People were cared for by staff who had received the appropriate training and had the skills and support to carry out their roles. Staff members understood and complied with the principles of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received a choice of meals, which they liked, and staff supported them to eat and drink. They were referred to health care professionals as needed and staff followed the advice professionals gave them.

Staff were caring, kind and treated people with respect. People were listened to and were involved in their care and what they did on a day to day basis. People’s right to privacy was maintained by the actions and care given by staff members.

People’s personal and health care needs were met and care records guided staff in how to do this. There was a variety of activities for people to do and take part in during the day, and people had enough social stimulation. Complaints were investigated and responded to and people knew who to speak with if they had concerns.

Staff worked well together and felt supported by the management team. The monitoring process looked at systems throughout the home, identified issues and staff took the appropriate action to resolve these.

Further information is in the detailed findings below.

This unannounced inspection took place on 9 December 2016.

Although appropriate action had been taken when any safeguarding concerns had been raised these had not always been reported to the Commission as required.

There was a staffing tool in place to calculate how many staff were needed to meet people’s needs. The staffing levels were sufficient to meet people’s basic needs. Extra staffing was sometimes required to support people when they displayed behaviour that challenged others. The registered manager had arranged for the extra staffing to be in place. The staff were not always aware of where people were and this could place them at risk.

Staff had access to personal protective equipment. This helped to decrease the risk of the spread of infection. People’s air mattress were regularly checked to ensure they were set at the appropriate levels to prevent them developing pressure sores.

' 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 describes what people using the service and the staff told us, what we observed and the records we looked at. If you would like to see the evidence that supports the summary, please read the full report.

We used a number of different methods to help us understand the experiences of people using the service. Some of the people had complex needs which meant they were not all able to tell us about their experiences. However, we observed the care being provided and spoke with eight people. We also spoke with, or received information from, two relatives, a GP who visited the home regularly, and 11 staff including two nurses, the manager of the home and two other managers who have line management responsibility for the home. We looked at staff training records, the provider's audits and five people's care records.

Is the service safe?

We found that each person had a care plan and associated risk assessments in place. However, we found that care plans had not all been updated to reflect the care being provided to people. We also found gaps in the recording of the daily care delivery. This was particularly in relation to records of people's food and fluid intake, repositioning to prevent pressure ulcers developing and continence management. Staff told us that the senior member of staff on each unit monitored these records. However, there was no record of this having taken place. This meant that it would be difficult for staff to ensure that people were getting the care they needed.

Is the service effective?

Staff received appropriate training and support for their role, including attendance at one to one and group meetings. Information supplied by the manager showed that staff had received training in relevant topics, including moving and handling, dementia awareness and end of life care. We noted that 33 of the 65 care staff had achieved a national vocational qualification (NVQ) in care.

Is the service caring?

Most people that we saw during our inspection were clean and well groomed. However, one person with long, dirty fingernails. The person indicated to us that they would like their nails cut. Records showed that the person hadn't had a shower or nail care in line with their care plan. This meant their needs had not been met.

People told us they were satisfied with the care they received. One person who had recently moved the home told us, 'This is quite good, I've not found any fault yet." Another person told us, 'The staff are lovely. You never hear raised voices to residents.'

Both relatives told us that they were happy with the care provided and that staff kept them informed of any changes in their family member's condition. One relative told us that they had the experience of a number of care homes. They said that, 'Some were more glamorous than this, but the care here has been better than anywhere else'.The staff do understand my [family member's] needs. Everyone's been brilliant.' The other relative also made positive comments but told us that when a new regime had been implemented this had only happened for a while and then stopped.

We spoke with a health care professional who visited people at the home regularly. They said they felt the home provided good care. They said, 'I really think this place is very good. I have no concerns and am happy with care and treatment provided.'

On the whole we saw that staff communicated well with people and provided sensitive assistance where people required support. They spoke in a calm and respectful way, giving time for people to respond to them. However, we heard one member of staff speak to people in a terse and patronising manner. We also heard this member of staff try to instigate a conversation with another member of staff, ignoring the person the other staff member was assisting. On two occasions we heard members of staff calling across communal areas, where other people were present, requesting information about people's care.

Is the service responsive?

Where people had capacity to make decisions for themselves, we found that staff consulted them before providing their care. However, none of the people we spoke with could remember seeing their care plan. Records did not show that people had been involved in writing their care plans.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that staff had received training in the MCA and the DoLS, and there were proper policies in place to ensure that people who could not make decisions for themselves were protected. However, these were not being consistently followed across the whole of the home. This meant that people may be at risk of decisions being made that were not in their best interest.

People told us that staff responded when they called for assistance and we saw most people had call bells within easy reach. However, we noted that one person was unable to reach their call bell. This meant the person may not have been able to summon assistance if they had needed it.

Is the service well-led?

Management of the home had not been stable in the last year. The last manager who was registered with the Care Quality Commission (CQC) left the service in May 2013. A manager had been appointed and taken up post, but they left earlier this year. The manager at the time of our inspection had taken up the post in late May 2013. Staff told us the current manager was approachable and that they felt able to talk with her.

The provider had a comprehensive quality assurance system in place to audit and monitor the quality of the service provided. The provider carried out regular surveys to obtain the views of people receiving care and other stakeholders, including relatives and visiting professionals. The responses received in May 2014 had been mainly positive and we saw that the current manager had reviewed these and taken action to address any shortfalls where appropriate.

Regular meetings were held for the people living in the home and their relatives and the various groups of staff. This provided an opportunity for people, their relatives and staff to voice their opinions and for the manager to share information.

There was a comprehensive programme of audits that the managers completed to monitor the service provided. We could see that where areas for improvement were identified, these had been followed up to ensure they had been actioned. However, we found one person's care plan had been audited and found to be 100% compliant with the provider's standard. However, we found that some important information was missing from the person's care plan. The manager rectified the shortfall immediately. The manager told us that following our inspection a Quality Officer was visiting the home and completing further audits of people's care plans. In addition they told us that they had taken steps to improve the record keeping in the home. This included the re-introduction of paper based charts for staff to record people's food and fluid intake.

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

People who lived there told us they were happy and one person said, 'I feel safe'.

Relatives we spoke with or who left us comments cards complimented the care and support staff gave people. One person said, "I haven't seen my (relative) smile so much in all the years I have known them. The staff are so kind'.

However, one person was concerned about the number of staff and told us they had seen people who had to wait over an hour to get help to go to the toilet.

The care delivered to people did not always meet the needs of people who were living with dementia. We also observed that when staff communicated with people, the level of their interactions varied. This was because some staff spoke with people in a very limited way while others were able to engage people with the activity or task and initiate conversations.

Staff made an effort to get to know people they cared for and treated them with sensitivity and understanding. However, this level of knowledge was not consistent on all units of the home and did not demonstrate a clear understanding of best practice guidelines in dementia care.

Evidence that we checked demonstrated that the provider worked well with other health and social care professionals to ensure people received ongoing support.

There were systems in place to monitor the quality of care that people received and make improvements as a result of learning from feedback.

Staffing levels had been increased to ensure people's care and support needs were being met in a timely way.

We found that although there were systems in place to prevent people being exposed to the risk of infection improvements were needed to ensure that appropriate standards of cleanliness were maintained.

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Since the previous inspection the manager had recruited staff to ensure that that any staff absence could be covered. However we found that staffing levels on the afternoon shift on the ground floor sometimes meant that people had to wait up to half an hour for assistance with personal care.

There were systems in place to ensure that staff received the training and support they needed so that they could safely provide care and treatment to people using the service.

The home had a variety of ways that they monitored the quality of the service being provided. People who lived in the home and their relatives were encouraged to give their views about the home and had been involved in decisions about their care.

People we spoke with told us they were happy at this home. They said staff treated them with respect and their privacy and dignity were maintained. One person said, 'I'm looked after very well. I'm very well treated and respected'. A family member said, 'I'm so pleased with the care my [relative] is getting'.

People told us they were able to make choices in most areas of their daily lives, including about the care they received, the food they ate and what they did during the day. However, people who needed staff to support them did tell us they sometimes had to wait for assistance when staff were busy.

A member of staff said, 'The management are really good, they provide everything for the residents who are looked after really well'. Another member of staff told us, 'I'm very happy here. It's really lovely. It's about the people; they [the company] genuinely care'.

People said they felt safe, they received the care they needed in the way they preferred, and they knew how to make a complaint.

People liked the staff. However there were not always enough staff to meet all their needs in a timely way.