Archived: St Marys

St Marys can support up to 60 older people in a residential type care home. Some people live with dementia and reside on Constable. This is a part of the home designed to keep people safe and supported by suitable staff. At the time of our inspection 34 people were residing at the service. This was because following our last inspection the provider decided to not admit anyone new to the home until they had made improvements. Since this inspection we have been notified by the provider that they are admitting people again on a phased introduction because they are confident that they have improved and can meet people needs.

There was a registered manager in post at the time of the inspection and they facilitated 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.

We found a service that had responded to our concerns and had focused its resources to improve the quality of service for people. People were involved and consulted about their quality of life. They were involved in decision making where possible and had developing opportunities in relation to day time activities and further opportunities being developed. Care plans were informative, regularly reviewed and enabled staff to provide consistent appropriate care based upon individual needs. Daily recordings were based upon plans, policies and procedures in place.

Risk assessments highlighted how people could be kept as safe as possible. People had access to healthcare support to remain healthy and were able to access medical support in the event of becoming unwell, an accident or a fall.

Staff were well supported. There were sufficient staff that worked flexibly to meet people’s needs. There was access to a team leader at all times. Staff were given the appropriate training to meet people’s needs and were able to gain professional recognised qualifications. There was an ongoing training program in place to support staff. Staff understood the aims and objectives of the service and worked towards and in line with these.

The management of the service was well regarded by staff, who told us they were visible and approachable and responsive to ideas. A full management team was now in place. Additional resources had been drawn to the service to support managers and staff to make the changes necessary in relation to care planning, training and management systems to ensure the quality of care delivery.

St Marys is a care home for older people. Some of whom are living with dementia. Up to 60 people can be accommodated. Constable is a part of the home that accommodates people living with dementia. At the time of our visit 23 people resided there. There were 44 people resident in total. Immediately after our inspection and feedback given the provider wrote to us to confirm that they would not admit any new person to the home. They agreed with CQC that they needed a time of consolidation and to improve the safety and quality of care afforded to people currently resident.

The newly appointed registered manager was unable to be present on day one and therefore we returned a second day specifically to meet and discuss matters that they had defined and were working on. 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.

People told us that staff were consistently kind to them. We observed some good interactions between people and staff. Staff demonstrated meaningful relationships with people. Activities were set to improve, but this was difficult to measure on the day as many things were planned, and yet to occur. Some people told us of a lack of stimulation and a desire from a small minority of staff for them to be fit in with the care being offered.

We had concerns about the healthcare and monitoring people at this service. We found examples of people who had not had swift intervention and ongoing monitoring when they had injured themselves. We found inconsistent monitoring and support for known medical conditions. Assessments relating to risks had not always been promptly reviewed and updated and therefore not all action was in place that could have been taken, to mitigate known risks to people. Care plans were in a period of transition from one set of paper work to another. The new model was an improvement on the previous files. However, we felt there was a true risk during this transition period of information not being known and actioned. Medicine management was not as robust as it could have been. People were receiving medication prescribed, but we fed back two matters to improve upon in terms of records of administration and controlled medicines.

Staffing levels were now appropriate and recruitment was on going, but we found a manager who was not confident to delegate to the senior team due to their lack of training and knowledge and therefore single handled was unable to maintain and develop a service in need of raising its standards. The provider had known our concerns when they purchased this service in late 2015, but we were unable to establish at this inspection progress to ‘good’ safe quality care. The provider had not ensured that systems to monitor and audit the quality of care and safety had been systematically competed, actioned and followed up on. The provider was not fully aware of the day to day running and if people were experiencing the best care and support possible.

We found that complaints were appropriately handled, but a minority of relatives had leapfrogged over the manager in post and had not been encouraged to use the systems in place to resolve matters at a local level by the registered manager. People told us that they had confidence in the new registered manager. Staff were positive about the changes that were being brought about and keen to work with the manager whom they respected. Feedback from local health and social care professionals was that they had confidence in the new manager and believed that in time this service would improve. We are kept updated and appropriately informed of notifications and events by the registered manager.

This is a summary of what we found:

Is the service safe?

We did not find that all areas of the service were safe.

Our inspection of September 2014 found that the registered person did not have suitable arrangements in place to ensure they complied with the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We also found that the registered person had not taken proper steps to ensure that each service users had been protected against the risks of receiving care or treatment that is inappropriate or unsafe. We also found that the registered person had not taken steps to report important events that affected people's welfare, health and safety, there were insufficient numbers of qualified, skilled and experienced staff to meet people's needs and the provider did not have effective systems in place to identify, assess and manage risks to the health, safety and welfare of people who use the service.

At this follow up inspection we checked to see if the required improvements had been made. Not everyone who lived at the service was able to communicate with us verbally due to their complex needs. To help us understand the care and treatment that people received we spent time observing care on Constable Unit which was an area of the service designated to care for people living with dementia. As part of this inspection we spoke with two relatives of people who used the service, four staff, the registered manager and the director of care services. We also examined care records, and records maintained by the service, in relation to the operation of the home.

We found that, although some improvements had been made to ensure mental capacity assessments were being completed, the provider had not implemented all of the measures as set out in their action plan. We found staff continued to have a varied understanding of the principles of the MCA and DoLS and when these pieces of legislation were applied, and staff training had not been provided in accordance with the timescales set out in the provider's action plan.

During the course of our inspection we identified a serious shortfall in relation to the way staff responded to allegations of abuse. An incident of alleged abuse had been witnessed by three members of staff, (two agency and one permanently employed member of staff) however, none of the staff on duty had reported this incident and the member of staff had remained on shift, providing unsupervised care to people who used the service. This placed people at risk of further harm.

Is the service effective?

We did not find that people received consistently effective care and support.

During our inspection, we spoke to the local authority adult protection team, who told us that they and other health care professionals were guiding the home significantly in identifying and addressing risks. There has been a failure at the service to address recurring areas of risk to people's health, safety and welfare, and to sustain improvements made. We observed one person walking around and requesting to go upstairs. A member of staff responded, telling them to sit down and to let them get on and they would take them upstairs later when they had finished what they were doing. We also saw records which confirmed several incidents of violent or aggressive behaviour. At the previous inspection in September 2014 we identified that staff had not been provided with training to ensure they had the skills and knowledge to support people appropriately, when faced with behaviour that challenged others. The director of care service and staff confirmed this training had not yet been provided. Therefore strategies to minimise risks to ensure people were protected from harm or the risks of harm had not been implemented.

Is the service caring?

We did not find that people received consistently effective care and support.

Although, we found staff to be kind and caring, we remained concerned that staff did not always respond to people's needs in a timely way. We found that staff were focussed on the completion of tasks, such as the provision of meals and personal care with minimal engagement with the people they were supporting.

Is the service responsive?

At this inspection we found evidence that showed the service had made significant improvements in relation to staffing levels and the monitoring of the needs of people who used the service in relation to the allocation of staff. The director of care services provided us with a formal assessment tool they had used, to determine the staffing levels needed to meet the needs of the people who used the service. This assessment tool identified the level of needs by looking at how many people had high needs, based on their personal care, nutrition and mobility needs, and needs based on a diagnosis of dementia and/or people who displayed behaviour that indicated excessive anxiety or distress. This document showed that the service was employing sufficient staff to cover all the required shifts needed to meet the needs of people who used the service.

Is the service well-led?

People were not protected against the risks of inappropriate or unsafe care as the provider had not taken steps to regularly identify, assess and manage risks relating to the health, welfare and safety of people who used the service.

We found that the service We looked at the quality monitoring reports and found that a number of audits had been undertaken, including staffing levels, medication, care plans, staff files, falls and nutritional needs. As result the service had implemented a number of improvements including, changing the medication system, improved levels of referrals to the falls team and dietetic services, where care records identified a need. Care plans had been reviewed and the director of care services advised and showed us a new care planning document, which they were introducing. However, the director of care services confirmed that the service had not undertaken any overall quality monitoring reports that assessed the quality and safety of the care provided to people who used the service. Similarly there had not been any formal means of seeking the views of people who used the service, family members or other professionals about the overall quality of care provided by the service. We found that some falls and accidents and incidents had been recorded, however it was not always clear what action had been taken.

At this inspection we looked at records of notifications received by CQC and those held in the service of incidents and found that formal notifications of incidents which affected the health and wellbeing of people who used the service had been made in line with legal requirements.

We also conducted our inspection to follow up on compliance actions made at our last inspection 11 June 2014 when we found concerns. These concerns related to the provider failing to assess the mental capacity of people who used the service. Further concerns related to the lack of appropriate checks being carried out before staff began working at the service. We asked the provider to send us their action plan describing what action they would take to ensure their compliance. The provider did not send us their action plan within the timescales specified. We received their action plan on the day of our inspection 09 September 2014.

Not everyone who lived at the service was able to communicate with us verbally due to their complex needs. To help us understand the care and treatment that people received we spent time observing care on Constable Unit which was an area of the service designated to care for people living with dementia. As part of this inspection we spoke with two relatives of people who used the service, four staff, the registered manager and the director of care services.

We considered our inspection findings to answer 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?

This is a summary of what we found:

Is the service safe?

We did not find that all areas of the service were safe.

The registered manager had a good understanding of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). There was one application in place to deprive a person of their liberty. However, we found that people who required constant supervision had not had their best interests assessed by those qualified to do so.

We found concerns with regards to the staffing levels on Constable Unit which was designated to provide care and support for people living with advanced dementia. Staffing levels were not consistently maintained and were found to be insufficient to meet people's needs. We have taken further action to protect people.

Is the service effective?

We did not find that people received consistently effective care and support.

One person who had been living at the service for 22 days did not have a care plan in place. Staff had not been provided with the written guidance they needed to ensure that the health, welfare and safety needs of this person would be met.

We were not satisfied that staff had been provided with the guidance they needed to support people appropriately and safely when faced with behaviour that challenged others.

We were concerned that staff had not been provided with the required skills and knowledge by the provider to enable staff to deliver care in such a way as to ensure the welfare and safety of people who used the service.

Is the service caring?

Staff supported and interacted with people in a friendly and supportive manner. However, staff were seen to be focussed on person care tasks and rushed. This meant that we could not be assured that the people who used the service received appropriate care and support.

Is the service responsive?

Where concerns about individual's safety and wellbeing had been identified, the provider had not taken appropriate action that ensured people were safeguarded from the risk of abuse.

Staff had not been provided with the required skills and knowledge they needed to deliver care in such a way as to ensure the welfare and safety of people who used the service.

People who had been assessed as requiring one to one support did not have their assessed needs met as the provider did not have sufficient staffing levels to meet their needs.

Is the service well-led?

Newly employed staff had not been provided with opportunities to shadow other staff. The manager told us that this was due to the shortages of staff as they were needed to work as part of the rota. This meant that the provider had not safeguarded the health, safety and welfare of people by taking appropriate steps to ensure that, at all times, there were sufficient numbers of suitably qualified and skilled staff.

The provider failed to notify us of reportable incidents as required. This meant that people who used the service could not be assured that the provider had taken steps to report important events that affect their welfare, health and safety so that, where needed action could be taken.

People were not protected against the risks of inappropriate or unsafe care as the provider had not taken steps to regularly identify, assess and manage risks relating to the health, welfare and safety of people who used the service.