Archived: St. John Home

St John Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

St John Home is registered to provide accommodation, nursing and personal care for 18 older people and younger adults. It can also accommodate people who require support to manage their mental health and people who have physical and/or sensory adaptive needs. There were 15 people living in the service at the time of our inspection visit all of whom were receiving nursing care.

The service was run by a charitable body who was the registered provider.

At the last comprehensive inspection on 16 August 2017 and 18 August 2017 the overall rating of the service was, ‘Requires Improvement’. We found three breaches of regulations. This was because people had not always been provided with safe care and treatment. In particular, there were shortfalls in the steps taken to reduce the risk of accidents and to ensure that people drank enough and dined safely. There were also oversights in the checks made to ensure the safe operation of bed rails and pressure relieving mattresses. In addition to this, suitable provision had not been made to obtain people’s consent to the care they received. Furthermore, the registered provider had not established robust systems and processes to monitor, assess and improve the service.

We told the registered provider to send us an action plan stating what improvements they intended to make and by when to address our concerns and to improve the key questions of 'Safe', 'Effective' and ‘Well Led' back to at least, 'Good'. After the inspection the registered provider told us that they had made the necessary improvements.

At the present inspection we found that sufficient progress had been made to meet each of the breaches of regulations. There were robust arrangements in place to ensure that people reliably received the nursing and personal care they needed. This included lessons being learned when things had gone wrong so that arrangements could be made to reduce the risk of people experiencing falls. It also included people being helped in the right way to drink enough and to eat safely. Furthermore, additional checks had been made to ensure that bed rails and pressure relieving mattresses were in a serviceable condition. Revised arrangements had been made to enable people to seek consent in line with national guidance. Additional quality checks had been introduced to enable the registered provider to better ensure that people received care that met their needs and expectations. However, in relation to this more progress was still needed as quality checks had not identified that additional steps needed to be taken for the service to comply with a change in best-practice guidance. We found that people had not always had information presented to them in an accessible way. This had reduced their ability to receive person-centred care that promoted their independence. This was because appropriate arrangements had not been made to implement the Accessible Information Standard 2016. We have made a recommendation in relation to this matter.

Our other findings were as follows: People were safeguarded from situations in which they may experience abuse including financial mistreatment. Medicines were managed safely. There were enough nurses and care staff on duty. Background checks had been completed before new nurses and care staff had been appointed. Suitable arrangements were in place to prevent and control infection.

People received nursing and personal care that was delivered in line with national guidance by nurses and care staff who had the knowledge and skills they needed. This included respecting people’s citizenship rights under the Equality Act 2010. People were supported to eat enough to have a balanced diet to promote their good health. Suitable steps had been taken to ensure that people received coordinated care when they used or moved between different services and people had been supported to access any healthcare services they needed. The accommodation was designed, adapted and decorated to meet people’s needs and expectations.

People were supported to have maximum choice and control of their lives. In addition, the registered provider had taken the necessary steps to ensure that people only received lawful care that was the least restrictive possible.

People were treated with kindness and they had been given emotional support when needed. They had also been helped to express their views about things that were important to them. This included them having access to lay advocates if necessary. Confidential information was kept private.

People received all the practical assistance they needed. People were given opportunities to pursue their hobbies and interests. Nurses and care staff recognised the importance of appropriately supporting people if they followed gay, lesbian, bisexual, transgender and intersex life-courses. Suitable arrangements were in place to resolve complaints to improve the quality of care. People were supported at the end of their life to have a comfortable, dignified and pain-free death.

There was no registered manager. However, there was a manager in post who had promoted an inclusive culture in the service. They were in the process of applying to be registered by us. People who lived in the service and members of staff were actively engaged in developing the service. Nurses and care staff had been supported to understand their responsibilities including speaking out if they had concerns about a person’s wellbeing. There were suitable arrangements in place to enable the duty of candour to be met. The registered provider had told us about any significant events that had occurred in the service. The quality ratings we had given the service were displayed in the right way. The registered provider was actively working in partnership with other agencies to support the development of joined-up care.

The St. John Home is owned by St John’s Ambulance. It has a charitable status and therefore is non-profit making. Accommodation is over two floors with a stair lift to the first floor. The service provides residential and nursing care with accommodation for up to 18 older people.

There was registered manager working at the service. 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 and associated Regulations about how the service is run. The registered manager had been in post since March 2017. As the service is a nursing home there is always at least one a registered nurse on duty 24 hours a day.

Some risks had been identified to people's health and welfare but full guidance to make sure all staff knew what action to take to keep people safe and manage risks was not always available. For example, when people were at risk of falling, or not drinking enough, or when their skin was at risk of breaking down the risk assessment did not contain the information needed to make sure risks were mitigated. This left people at risk of not receiving the support they needed to keep them as safe as possible. Accidents and incidents had been recorded but there was no analysis or oversight of the accidents and incidents. Triggers, patterns and interventions had not been identified to try and reduce the risk of re-occurrence.

The registered manager and staff carried out environmental and health and safety checks to ensure that the environment was safe and that equipment was in good working order, however some checks and audits had not been completed. When shortfalls had been identified, action had not been taken to reduce risks and make improvements. When the water temperatures were recorded as exceeding the recommended limits action had not been taken to make sure they were safe. The provider had sought feedback from people but had not analysed the results. They had not asked relatives, staff and other stakeholders for their views so that improvements could be made.

People, staff and relatives told us that the service was well led and that the registered manager was supportive and approachable. However, the registered manager did not have full oversight and scrutiny of the service. They were not effectively supported by the provider’s systems and processes. The registered manager was developing a culture of openness and transparency within the service.

Emergency plans were in place so if an emergency happened, like a fire, staff should know what action to take. Not everyone’s personal evacuation emergency plans (PEEPS) contained all the information to explain what individual support people needed to leave the building safely. Regular fire drills had not taken place. During the inspection we contacted the fire officer to tell them of our concerns. A fire safety company had recently visited the service and remedial work had been undertaken on the emergency lighting and extra smoke detectors had been fitted.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The registered manager was not fully aware of a judicial review which widened and clarified the definition of a deprivation of liberty. The registered manager and staff had a lack of understanding about their responsibilities under the Mental Capacity Act 2005 and DoLS. Mental capacity assessments had not been consistently completed by the staff to decide whether or not people were able to make decisions themselves. At the time of the inspection the registered manager had not applied for DoLs for people who may need them. When people did not have the capacity to make complex decisions, they were supported by relatives, doctors and other specialists involved in their care and treatment to make a decision that was in their best interest.

People received their medicines safely and when they needed them and they were monitored for any side effects. On occasions medicine practices were not as safe as they could be. When people received medicines on a ‘when required’ basis there was no guidance in place to make sure they received it consistently and safely. There were no guidance to explain to staff where to apply creams and sprays to people’s skin.

The complaints procedure that was available to people and others was not relevant to St John Home and the type of service they provided. People and their relatives did know how and who to complain to. They felt they would be listened to and action would be taken to resolve their complaint should they have any complaint. People felt safe using the service and were protected from the risk of abuse. Staff knew the possible signs of abuse and how to alert the registered manager or the local authority

Before people decided to move into the service their support needs were assessed to make sure the service would be able to offer them the care that they needed. People and their relatives said that they were satisfied and happy with the care and support they received The registered manager and staff were in the process of reviewing and updating care plans. Some care plans contained the detail needed to show how all aspects of people’s care was being provided in the way they preferred. Other care plans needed further personalised information to ensure that people received consistent care and treatment in the way they preferred.

Everyone had an allocated key worker. Key workers were members of staff who took a key role in co-ordinating a person's care and support and promoted continuity of support between the staff team.

There were activities provided for people. People said they would like to do more. They told us they sometimes got a bit bored. The registered manager was in the process of developing more activities for people and had recently appointed a member of staff to organise different and varied activities for people.

People were supported to have a nutritious diet. Their nutritional needs were monitored and appropriate referrals were made to specialist teams such as dieticians when it was necessary. The staff were effective in monitoring people's health needs and sought professional advice when it was required. If people were unwell or their health was deteriorating the staff contacted their doctors or specialist services.

Staff understood people's specific needs and had good relationships with them. Most of the time people were settled, happy and contented. Throughout the inspection people were treated with dignity and kindness. People's privacy was respected and they were able to make choices about their day to day lives. Staff were respectful and caring when they were supporting people. When people became anxious staff took time to sit and talk with them until they became settled. People's confidentiality was respected and their records were stored securely.

Staff were familiar with people's life stories and were very knowledgeable about people's likes, dislikes, preferences and care needs. They approached people using a calm, friendly manner which people responded to positively.

New staff received a comprehensive induction, which included shadowing more senior staff. Staff had regular training and additional specialist training to make sure that they had the right knowledge and skills to meet people's needs effectively. Staff said they could go to the registered manager and they would be listened to. Staff fully understood their roles and responsibilities as well as the values of the service.

A system to recruit new staff was in place. This made sure that the staff employed to support people were fit to do so. There were sufficient numbers of staff on duty throughout the day and night to make sure people were safe and received the care and support that they needed.

Services that provide health and social care to people are required to inform the Care Quality Commission, (CQC), of important events that happen in the service. CQC check that appropriate action had been taken. The register manager had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

It is a legal requirement that a provider’s latest CQC inspection report rating is displayed at the service where a rating has been given. This is so that people, visitors and those seeking information about the service can be informed of our judgments. We found the provider had conspicuously displayed their rating in the hallway.