St George's Nursing Home (Oldham)

St George’s Care Centre is located in the residential area of Moorside, Oldham. It is approximately three miles from Oldham town centre and is situated close to local shops and amenities, with good access to local transport routes.

This was an unannounced inspection which took place on 22, 23 and 25 January 2019. The care Quality Commission (CQC) last inspected St George’s Care Centre in November 2017, when the service was rated as ‘Requires Improvement’ overall. At that inspection we found the service was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safe care and treatment. This was because medicines were not always managed safely. Following our inspection, the service provided us with an action plan which described how they would make improvements. At this inspection we found improvements had been made and the service was no longer in breach of any of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had an experienced registered manager, who was a registered mental health nurse. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The building was secure, clean and well maintained. There were effective infection control and prevention measures within the service. Checks and servicing of equipment, such as for the gas, electricity and fire-fighting equipment were up-to-date.

Staff had been recruited safely. The service had completed all the necessary checks to ensure that staff were suitable to work with vulnerable people. There were enough registered nurses, care workers and support staff to meet the needs of the people who currently lived at the home. There was an on-going recruitment drive with the aim of reducing the use of agency staff.

A safe system of medicine management was in place.

People had individual assessments in place which identified risks in relation to their health and wellbeing. These helped identify if people were at risk from everyday harms, such as falls. Where risks were found, there were plans in place to guide staff, so that people were kept safe.

Accidents, incidents and safeguarding concerns were recorded and managed appropriately. There was clear information detailing any remedial action taken to reduce the likelihood of similar events occurring in the future.

We observed that staff always considered people’s capacity and consent when supporting them with care tasks. People were given choices when making everyday decisions. When people were being deprived of their liberty the correct processes had been followed to ensure that this was done within the current legislation

People were supported by well-trained staff. New staff received a thorough induction to the service and the training matrix showed that all staff had completed face-to-face training in a range of topics. Senior nurses and management carried out regular supervision and observation of staff. This ensured the standard of their work was monitored and gave them the opportunity to raise any concerns or worries.

During our observations we found staff treated people with dignity and respect. Staff showed patience and understanding and interacted with people in a kind and caring manner.

Staff at St George’s monitored people’s health. Where specific healthcare needs were identified, such as weight loss, the service liaised with health care professionals for specialist advice and support. Nursing staff were always available to undertake nursing duties, such as wound care and end of life care. People were supported to eat a well-balanced diet and were offered a choice of home-cooked meals.

People's care records were person-centred and contained detailed information about their preferred routines, likes and dislikes and how they wished to be supported. Providing person-centred care is about ensuring someone with a disability or long-term condition is at the centre of decisions about their life.

People were encouraged to provide feedback through service user meetings, an annual survey and via ‘Quick Response Code’ which was displayed in the reception area. This is a digital method of providing feedback.

The management team provided strong leadership of the service and was committed to maintaining and improving standards. Audits and quality checks were undertaken on a regular basis and any issues or concerns addressed with appropriate actions.

We carried out an unannounced focussed inspection on 2 and 3 February 2017. That inspection was to check if the service had made the necessary improvements and also because we had been made aware of an incident which indicated potential concerns around the management of the risk associated with bed rails. At that inspection we specifically looked at the ‘safe’ and ‘well-led’ domains. We found that, although some improvements had been made, there was a continued breach of the regulations the service was in breach of at our October 2016 inspection. Namely, we again found concerns around the management of medicines. We also identified that where people were using bed rails, there was no risk assessment in place to identify if they were safe to use for each individual person. This demonstrated a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider had failed to maintain the quality and safety of the service. At that inspection we rated the ‘safe’ domain as inadequate.

We carried out this inspection on 8 and 9 November 2017. This inspection was to check what improvements had been made and to rate the service. We found that overall the service had made considerable improvements since our last two previous inspections. However, we found that medicines were not always managed safely and there was therefore a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Medicines were not always stored at the correct temperature. Some medicines may become ineffective if stored above or below the recommended temperatures. We found eye drops for two people were past their recommended expiry date. This meant we could not be sure if they were still effective. Where people received their medicines covertly (hidden in food or drink) there was no record of any input from a pharmacist to advise the home how to disguise each medicine without reducing its effectiveness. We identified some issues around the recording of fluid thickeners.

There were systems in place to help safeguard people from abuse. Staff understood what action they should take to protect vulnerable people in their care. Recruitment checks had been carried out on all staff to ensure they were suitable to work in a care setting with vulnerable people. At the time of our inspection there were sufficient staff to respond to the needs of people promptly.

The home was clean, well-maintained and well-decorated. Procedures were in place to prevent and control the spread of infection. Maintenance checks on services, such as the gas and electricity supplies and checks on equipment, such as hoists were in date. There were systems in place to protect staff and people who used the service from the risk of fire.

All new staff received a thorough induction and regular refresher training was undertaken by staff to ensure they had the skills and knowledge required for their roles. Staff received regular supervision which gave them an opportunity to discuss any work related problems and identify training needs.

Staff encouraged people to make choices where they were able. The service was working within the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

People were provided with a good choice of food. Where people were found to be at risk of malnutrition they had been referred to a dietician for specialist help. People had good access to other health professionals when needed.

We observed kind and caring interactions between staff and people who used the service. Care plans, which were reviewed regularly, were detailed and reflected the needs of each individual.

There were a range of policies available for staff to refer to for guidance on best practice. Systems were in place to monitor the quality of the service and drive improvement. However, our concerns around medicines management had not been identified by the auditing process.

We carried out an unannounced comprehensive inspection of this service on the 4 and 5 October 2016. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment and good governance. We took enforcement action against the provider and issued Warning Notices and asked them to make improvements to the service.

We undertook this unannounced focused inspection on 2 and 3 February 2017 to check that they had followed their plan and to confirm that they now met legal requirements. We had also received a notification of an incident at the home involving a person who used the service. The information shared with CQC about the incident indicated potential concerns about the management of risk around the use of bed rails. As part of this inspection we examined those risks. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk.

At the time of this inspection there was a registered manager in post who had registered with the Care Quality in June 2016. 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.

During this inspection we identified that the registered provider had not notified the Care Quality Commission of an incident that had resulted in a person sustaining a serious injury. The registered provider has a legal responsibility to inform the CQC of notifiable incidents. Failure to notify the CQC of this incident was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

We found that although some improvements had been made in relation to the concerns we identified in October 2016, these had not yet been fully rectified. In addition, at this inspection we identified concerns around risk assessments, in particular that the provider was not completing bed rail risk assessments.

We identified there were continuing breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Safe care and treatment and Good Governance. These were in relation to medicines management and lack of appropriate risk assessments; and failure to monitor the quality and safety of the service. You can see what action we told the provider to take at the back of the full version of the report. We are currently considering our options in relation to enforcement in relation to some of the breaches of regulations identified. We will update the section at the back of the inspection report once any enforcement work has concluded.

At our inspection in October 2016 we found shortfalls in the administration of medicines as policies and procedures for the safe storage, administration and recording of medicines were not always followed. At this inspection we found that although some improvements had been made, there continued to be problems with the safe administration and storage of medicines.

At our inspection in October 2016 we identified that hazardous substances such as fluid thickening agents were not stored securely. At this inspection we found this concern had been rectified and all hazardous substances were safely stored out of reach of people who used the service.

During our inspection in October 2016 we identified problems with the cleanliness of some areas of the home, and of equipment. We also found that personal toiletries were left in bathrooms. During this inspection we saw that although there had been some improvement in cleanliness we still found some areas in the home that were not cleaned to a high standard. For example the carpets in the lounges of Brook and Beal units were dirty and stained. The registered manager told us that she was looking into purchasing a carpet cleaner for the home, and that there was an ongoing programme of carpet replacement for the bedroom carpets.

We found that not all the people who used the service who required bed rail risk assessments had them in place. We had identified this issue prior to our inspection and during our inspection we found that the provider had started to implement bed rail risk assessments for all people who used bed rails within the home. However, at the time of our inspection this was not yet complete.

At our inspection in October 2016 we found shortfalls in some aspects of the management of the service, as systems for monitoring the quality and safety of the service were not sufficiently robust to identify some of the concerns we found during that inspection. At this inspection we found that although the provider had made some improvements there continued to be problems around safe administration of medicines, managing risk, cleanliness and monitoring the quality of the service.

The overall rating for this service is ‘Requires improvement’, however the service has been rated “Inadequate” in a key question and will be re-inspected within six months. If there remains an inadequate rating after six months, in any key question the service will go into special measures

The inspection was carried out on 4 and 5 October 2016 and was unannounced. The inspection was carried out by two inspectors and a specialist advisor.

A registered manager was in post and had registered with the Care Quality Commission in June 2016. 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.

We found shortfalls in the administration of medicines as policies and procedures for the safe storage, administration and recording of medicines were not always followed. We also found that some areas of the home were not kept satisfactorily clean, and that hazardous substances were not always stored safely. The registered manager had addressed some of our concerns by the second day of the inspection.

Staff had received training in the safeguarding of vulnerable adults and the service followed the protocols set out by the local authority for the recording and reporting of incidents of a safeguarding nature.

There were suitable numbers of staff on duty, and safe staff recruitment processes were in place which helped to protect people from abuse. There were some staff vacancies and recruitment was in progress to fill these. Where agency staff were being used, the registered manager tried to book the same agency staff to provide consistency and continuity of care.

Systems were in place to assess and monitor the safety of the premises and equipment. Individual risks to people were also assessed and plans were put in place to mitigate these.

Staff received regular training, supervision and appraisals. A new system had been put in place to ensure these were brought up to date by the new registered manager, as a number had been out of date. We found that progress was being made in this area and staff told us they felt well supported. A training facilitator worked in the service and was responsible for planning and delivering training. Specialist trainers were brought in to provide training related to specific needs, such as particular medical conditions or specialist equipment. There were some gaps in training but there were plans in place to address these. The standard of training materials and resources was high.

The service was working within the principles of the Mental Capacity Act and applications had been made to the local authority to deprive people of their liberty in line with legal requirements. Decisions taken in the best interests of people were not always appropriately recorded or reviewed on a regular basis.

People were supported with eating and drinking, and special diets were catered for. Nutritional assessments were carried out, and where people were found to be losing weight, specialist input was sought. There were mixed views about the quality of the food, and we were told that the contract with the external catering company was due to end, and that catering would be provided by the provider’s organisation in the near future. We reviewed food and fluid records and observed staff completing these. We found that they were not always completed accurately and that there were some gaps in records.

The premises were generally clean and tidy, and there was access to outdoor space with supervision. Gardens were well maintained and tidy. There was a rehabilitation kitchen, hairdresser and old fashioned sweet shop on site. The design supported the needs of people living with dementia, including good use of signage to support way finding. Some towels and bedding although clean, were worn, and the registered manager told us she had recently ordered replacements.

Staff were observed to be kind and caring in their interactions with people throughout the inspection. The units we visited were calm and staff communicated with people in reassuring tones. We observed that when people became upset, staff intervened quickly. We observed people interacting with staff with warmth and humour, and they told us that they felt well cared for and that staff were nice. People’s privacy and dignity was respected and promoted.

Care plans were in place which contained person centred information. These varied in quality and format and it was not always easy to locate the most up to date information. The registered manager had set up a working group to review, streamline and standardise care records. We found that essential information and care plans to meet people's needs was available in the main but that care plans needed to be further developed. We have made a recommendation about this.

A number of activities were available to people. We observed people taking part in activities during the inspection and they were well supported by staff to take part. Three activity coordinators were in post which meant that activities could take place over seven days per week.

A complaints procedure was in place and a log of any complaints was maintained. We saw that complaints received had been responded to appropriately by the manager. Systems were being improved to capture low level issues to improve the quality of the service by addressing concerns at the earliest opportunity.

We found shortfalls in some aspects of the management of the service. Systems for monitoring the quality and safety of the service were not sufficiently robust to pick up some of the concerns we identified during the inspection. The registered manager was keen to address issues we identified as soon as possible. They had made improvements in a number of areas and told us they planned to use the inspection outcome as a benchmark from which to continue to make improvements.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to safe care and treatment and good governance.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.