Archived: St Georges Care Home

St Georges Care Home is a care home registered to provide accommodation and personal care to a maximum of 35 older people. At the time of the inspection there were 24 people living in the service.

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

Risks to people had not always been identified and planned for. This meant staff did not always have access to information which could guide them on how to reduce risks.

There was a spate of chest infections and colds in the service, but no management plan to reduce the spread of this was in place. Infection control was poor, mattress covers were stained with a substance whose odour and appearance was consistent with urine and there were unpleasant odours throughout the service.

The support people needed to reach and maintain a healthy weight was not always documented.

People’s dignity was not always upheld by staff who were not discreet when providing people with support. The actions of care staff were not always caring.

Staff were disorganised, and this meant people were left in some communal areas with no staff presence for extended periods of time. People’s requests for support were not always met in a timely manner.

At the last inspection in February 2019 the service was rated requires improvement overall. At this inspection standards were found to have fallen and people were placed at risk of harm and receiving poor care. The quality assurance system in place had not identified all of the shortfalls we identified during our inspection. People, staff and professionals from external organisations told us the management team was not visible in the service. Concerns were raised with us about the effectiveness of the manager in driving improvement. External healthcare professionals told us the manager did not deliver on actions they told us they would take within the timescales specified.

Following our second visit, we wrote to the provider about our concerns and asked them what action they would be taking to address the immediate risks we had identified. We returned for a third visit to ensure that they had taken the action detailed in their response to our letter. We found they had mitigated our immediate concerns and we were reassured by plans in place to mitigate risks to other people.

People’s medicines were administered as per the instructions of the prescriber. However, some poor practice was evident with medicines records not always being signed.

Improvements had been made ensure that people’s views about their care were reflected in care planning. Care plans were more personalised to include information about people’s preferences and life history.

Improvements had been made to ensure that people’s capacity to make decisions was assessed under the Mental Capacity Act 2005 and that Deprivation of Liberty Safeguards (DoLS) applications were made where appropriate.

Despite the concerns we identified, people told us they felt safe and that staff were nice to them. Recruitment procedures were safe.

The overall rating for this service is ‘Inadequate’ and the service remains

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.

You can see what action we have asked the provider to take at the end of this full report.

Rating at last inspection: The last rating for this service was requires improvement (published 11 April 2019).

Why we inspected

This was a planned inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

¿ People told us and we observed that staff were kind and caring in their interactions with them.

¿ The systems for checking the quality and safety of the service had again failed to identify where improvement was required. Audits were not sufficiently robust to identify concerns we found during this inspection. This put people at risk of potential harm.

¿ Further improvement was needed to ensure identified risks contained clear guidance on how these should be managed. Some risks, such as choking, did not have an associated plan of care to guide staff on how to reduce the risk, and action to take if a person was to choke. Where people had health conditions such as epilepsy or diabetes, there were not always risk assessments in place so staff knew how to recognise signs that they were becoming unwell and how to support them if their health condition deteriorated.

¿ Care plans were now more person-centred and included information on people’s life history and what their preferences were in relation to how their care was delivered. However, we found that care plans were not always sufficiently detailed where people had health conditions, and sometimes there was conflicting information contained within them.

¿ Food and fluid charts were in place for people at risk of malnutrition or dehydration so staff could monitor this. However, we found some conflicting information in care plans relating to people’s dietary needs.

¿ The Mental Capacity Act 2005 Deprivation of Liberty Safeguards were not fully understood by the registered manager. Applications to deprive people of their liberty had not been made in line with this Act to ensure care was lawful.

¿ People received their medicines by staff who had received relevant training. However, medicine administration records were not always completed in line with best practice, and we found two medicines in use had expired. Staff were not periodically assessed for competence in managing people’s medicines.

¿ Staff received training relevant to the people they were caring for. However, other areas of required training, such as diabetes, management of challenging behaviours and end of life care had not been planned.

¿ Staff understood the need to keep people safe from abuse and what was required to do this. Staff had received training in this area, and were clear they would report concerns to a manager or appropriate outside agency without delay. However, referrals had not always been raised by the registered manager.

¿ The overall rating for this service remains ‘Requires Improvement’. The rating for well-led is inadequate. This is the second consecutive inadequate rating for well-led, which means the service will now enter special measures.

¿ Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will act in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will act to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Rating at last inspection: At the last inspection the service was rated ‘Requires Improvement’ (Report published August 2018.)

Why we inspected: We inspected this service in line with our inspection schedule for services currently rated ‘Inadequate’ in any one of the five key questions.

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

Follow up: We will continue to monitor this service according to our inspection schedule in line with services in special measures.

At the last inspection on 19 January 2017 the service was rated Requires Improvement overall. The service was breaching Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service provided us with an action plan stating how they intended to improve in this area. At this inspection we found that the service had failed to make sufficient improvements to comply with this regulation. The service remains ‘Requires Improvement’ overall.

There was a registered manager 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 2008 and associated Regulations about how the service is run.

Risks to people were not always identified and clear plans to mitigate risks were not in place for all the people whose records we reviewed. The registered manager and care staff did not always recognise risks in the environment, such as items which could cause potential harm. Care planning did not always make it clear how care should be delivered to ensure people’s safety.

The service was meeting the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Care planning around nutrition and hydration was not consistently clear about the support people required. The service did not follow NICE guidance around the assessment of nutrition and the actions required when people were assessed as at risk of malnutrition. NICE guidance is publically available and provides the reader with up to date information about best practice in providing care to people.

People and/or their representatives were not consistently involved in the planning of care. People told us they didn’t think they had been involved in creating their care plans and the records we reviewed did not reflect people’s views and preferences.

People’s records were not sufficiently personalised to include information about their likes, dislikes, hobbies and interests. Where people were living with dementia, there were not sufficient life histories in place. Care plans did not set out peoples preferences around how they would like their care delivered. This meant that staff did not have the information needed to deliver personalised care.

Sufficient end of life care plans were not in place. The service had not referred to NICE guidance and the Gold Standards Framework to create care plans that set out people’s wishes and needs in sufficient detail.

Whilst some work was being carried out to replace carpeting in some areas, the carpets in other areas remained heavily stained and required replacement.

Whilst the service had implemented some new audit systems and processes since our previous inspection, progress to comply with regulations remained slow. The service has been rated ‘Requires Improvement’ since 30 April 2015. At this inspection the service remains ‘Requires Improvement’ and in breach of regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not carry out robust, thorough and questioning audits of the service capable of identifying areas for improvement. The provider had not ensured that appropriate support was given to the registered manager to make the required improvements to the service. This meant that people continued to receive care which fell below the expected standard.

People and their relatives told us they felt their relative was safe living in the service and that staff made people feel safe. Medicines were stored, managed and administered safely.

People and their relatives told us there were enough suitably knowledgeable staff to provide people with the care they required promptly. Staff were satisfied with the quality and range of training available to them. There were safe recruitment procedures in place.

Staff received appropriate supervision which helped them develop in their role.

People and their relatives told us staff were kind to people and respected their right to privacy. People told us staff supported them to remain independent and our observations supported this.

People we spoke with said they were encouraged to feed back on the service and participate in meetings to shape the future of the service.

We observed that people were supported to access meaningful activities and follow their individual interests. People we spoke with were complimentary about the availability of activity and stimulation.

The home was decorated in a way which helped people living with dementia find their way to key areas such as the bathroom and their bedroom. The walls in the home were adorned with colourful paintings and murals which were stimulating to the eye. Ample sources of engagement were available around the home for people to access independently.

The registered manager created a culture of openness and transparency within the service. Staff told us that the registered manager was visible and led by example. Our observations supported this. People told us they knew how to complain and felt they would be listened to.

Further information is in the detailed findings below.

A registered manager was in post. 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.

At our comprehensive inspection of 13 and 21 July 2016, we found there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were needed regarding staffing, safe care and treatment, person centred care and respect and dignity. A warning notice was served to the provider and registered manager for failing to comply with good governance.

We met with the provider’s nominated individual and the registered manager 13 October 2016 to discuss their action plan in response to our inspection findings. We were given assurances that the shortfalls would be addressed.

During this inspection we found that improvements had been made in the service and were ongoing. Although the warning notice had been met, further improvements to staffing arrangements and people’s meal time experience were required. The registered manager had made improvements in how the service monitored and checked the quality of care provided but this was a work in progress. These measures need to be sustained and embedded into practice.

People and relatives were complimentary about the care and support provided. Staff respected people’s privacy and dignity and interacted with people in a kind and compassionate manner. They were knowledgeable about people’s choices, views and preferences and acted on what they said.

There was a positive culture within the service; staff was aware of the provider’s values and understood their roles and responsibilities. The atmosphere in the service was friendly and welcoming.

Staff were trained and supported to meet the needs of the people who used the service. They knew how to minimise risks and provide people with safe care. Procedures and processes guided staff on how to ensure the safety of the people who used the service. These included checks on the environment and risk assessments which identified how risks to people were minimised.

Appropriate arrangements were in place to ensure people’s medicines were obtained, stored and administered safely. People were encouraged to attend appointments with other health care professionals to maintain their health and well-being.

People and or their representatives, where appropriate, were involved in making decisions about their care and support arrangements. As a result people received care and support which was planned and delivered to meet their specific needs. Staff listened to people and acted on what they said.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Staff understood the need to obtain consent when providing care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Improvements to people’s care records had been made and were ongoing to ensure they were accurate and reflected individual needs and preferences.

People were provided with the opportunity to participate in activities and to pursue individual interests.

Processes were in place that encouraged feedback from people who used the service, relatives, and visiting professionals. People knew how to make a complaint if they were unhappy with the service.

St Georges Care Home provides accommodation, care and support for up to 35 older people, some living with dementia. At the time of our inspection there were 29 people using the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At our last inspection 30 April 2015, we found that the registered manager had not sent us information that we expect them to send us routinely in the form of statutory notifications. This is information about important events they are required to send us by law. During this inspection we found that they had addressed this issue.

At the last inspection we found a breach of Regulation 17 HSCA (RA) Good governance. Shortfalls identified the provider was failing to seek and act on feedback from people for the purpose of continually evaluating and improving the service. In addition systems were not in place to monitor the quality of the service and keep records of the outcome.

During this inspection we found there were still problems with the systems in place to assess and monitor the safety and quality of service provision. Leading to a lack of governance and oversight in line with current regulations. Existing quality assurance systems were failing to protect people from the risks of receiving inappropriate or unsafe care and treatment. Appropriate action to independently identify, assess and manage risks relating to the health, welfare and safety of people and others who may be at risk had not been established.

We also found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to staffing, person- centred care, respect and dignity, safe care treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

The provider was failing to ensure that the service was operating effectively to ensure that people were receiving safe and effective care. There were gaps in how the service assessed and monitored the quality of its provision. While there were some quality assurance mechanisms in place, these had proved ineffective at identifying areas for improvement, and not all aspects of the service were being effectively monitored. The provider did not have robust oversight of the service's operations and this was impacting on the quality of the care delivered.

People were not consistently supported by sufficient numbers of staff who were effectively deployed to meet people’s needs. There were occasions, for example at meal times where staffing levels were not appropriately deployed to ensure people had a good mealtime experience. At times care was task focussed and hurried with staff unable to respond to people promptly.

Risk assessments did not consistently provide staff with guidance on how risks to people were minimised. Improvements were needed to ensure people consistently received care and support that was personalised to them and met their individual needs and wishes. Staff did not always respect people’s privacy and dignity and interact with them in a caring, compassionate and professional manner.

People’s experience of how they spend their days was inconsistent. Whilst there were some areas of good practice with regards to group activities and social stimulation there were also several instances where people were left for periods of time with little or no interaction. Improvements were needed to ensure people especially those living with dementia spent their time in meaningful and fulfilled ways.

There were areas in the service where equipment was not always stored safely and where people’s individual needs were not safely met by the adaptation design and decoration of the service.

Robust systems were not in place to ensure care and support was based on the assessed needs of each person and reflected in their care records. Care plans for people were not effectively reviewed or reflective of people’s up to date needs. Risk assessments in relation to people's personal care, moving and handling and medicines had been completed to keep people safe. However, we found that the information held was not consistent across the service, and this meant that staff did not always have accurate and clear guidance to help them support people safely at the service.

Improvements were needed to ensure appropriate arrangements were in place to ensure people’s medicines were administered and recorded safely.

Safe recruitment checks on staff were carried out. Staff were trained to meet people’s needs. However improvements were needed to ensure staff received regular supervision to feel confident in their role and care for people safely.

People and relatives were complimentary about the care and support provided.

Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. Staff understood the various types of abuse and knew who to report any concerns to.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLs). Appropriate mental capacity assessments and best interest decisions had been undertaken by relevant professionals. This ensured that the decision was taken in accordance with the Mental Capacity Act (MCA) 2005, DoLS and associated Codes of Practice

People and relatives said if they needed to make a complaint they would know how to. There was a complaints procedure in place for people to access if they needed to. However complaints and feedback received could be used more routinely as an opportunity to learn and improve the service.

This is a summary of what we found;

Is the service safe?

When we arrived at the service a staff member looked at our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

We saw records which showed that the staff working at the home had access to the service's and the local authorities safeguarding vulnerable adults policies and procedures. We also confirmed that all staff received formal training in safeguarding vulnerable adults on a regular basis. The manager told us that they had not recently needed to make a Deprivation of Liberty Safeguards (DoLS) referral to the local authority. However, they were aware of when this may be needed. We also reviewed records of staff training which showed that training in this area, and the related requirements of the Mental Capacity Act, was provided to staff.

Is the service effective?

People told us that they felt that they were provided with a service that met their needs. One person said, "I am very happy living here."

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with kindness.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with their wishes.

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken into account and listened to.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and district nurse.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The manager had a quality assurance system and records reviewed by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

People told us that the staff treated them with respect and kindness. This was confirmed in our observations during our inspection. We saw that staff interacted with people in a caring, respectful and professional manner. We found that before people received any care or treatment they were asked for their consent and the staff acted in accordance with their wishes.

We spoke with a person's relative who told us, "I know that (relative) is happy with the food and the people here."

We looked at the care records of five people who used the service and found that people experienced care, treatment and support that met their needs and protected their rights. People were protected from the risks of inadequate nutrition and dehydration.

Staff personnel records that were seen showed that staff were trained to meet the needs of the people who used the service. However, they were not provided with appropriate supervision to ensure they received feedback regarding their work practice.

We found that people were cared for in a clean, hygienic environment and were protected from unsafe or unsuitable equipment.

There was an effective complaints system available.

We found that the provider had taken actions to ensure that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

People told us that the staff treated them with respect, listened to their choices and acted on what they said. One person said, "All the staff are lovely." Two people told us about what they had for breakfast and how they always chose what they wanted to eat. Two people's relatives told us that they were consulted about the care that their relatives were provided with and kept updated with issues about their wellbeing. They told us that the staff were always respectful.

We saw that staff interacted with people in a caring and respectful manner. People were offered choices such as what they wanted to eat and drink. Staff were attentive to the needs of people who used the service and responded to verbal and non verbal requests for assistance promptly.