The Georgians (Boston) Limited - 50 Wide Bargate Boston

We found the following examples of good practice.

¿ At the time of our visit, there was a outbreak of COVID-19 at the service, this was being managed well and staff were following robust procedures to manage the outbreak.

¿ There was clear information and guidance on managing COVID-19 visible to staff, residents and any visitors coming into the service. Visitors were screened before entry and where applicable COVID-19 vaccination status was confirmed. Visitors were supported to wear appropriate Personal Protective Equipment (PPE).

¿ There were adequate PPE supplies in place at various key areas in the service to ensure safe infection prevention and control practices were undertaken.

¿There was a cleaning programme in place and the service was visibly clean and well maintained.

¿ The provider had ensured staff were skilled in infection prevention and control (IPC) practices. This included up to date training on infection control and 'Donning and Doffing', (how to put on and remove) PPE.

¿There was a testing programme in place for staff and people living in the service. This was to ensure any staff or people who had contracted COVID-19 and were asymptomatic, were identified in a timely way.

¿ Staff promoted and practised safe social distancing throughout the home as far as was reasonably practical. Clear systems were in place to shield and isolate people should outbreaks occur.

¿ The service had created space to enable visitors to visit safely, this included the provision of a visitor’s room. Furthermore, plans were underway to create an external visiting space in the garden.

¿ People admitted to the service were supported in line with government guidance on managing new admissions during the COVID-19 pandemic.

The Georgians is a residential care home providing nursing and personal care of up to 40 people. There were 29 people using the service at the time of our inspection.

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

The provider had taken action to keep people safe from personal and environmental risks. This included management of the environment during the COVID- 19 pandemic. Medicines were well-managed, and people received their medicines on time and in line with their prescriptions.

There were enough staff to meet people’s needs and care was planned to keep people safe and increase their well-being.

The provider had systems in place to monitor the quality of care provided and took action to improve the service when needed. The provider ensured that people and their relatives were involved in the care provided.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was Good (published 18 December 2018).

Why we inspected

We undertook this focused inspection to follow up on concerns we had received. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions were not looked at on this occasion. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service was Good.

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.

The Georgians is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Georgians accommodates up to 40 people in one adapted building. It provides nursing and residential care for older people, some of who may be living with dementia and people with physical disabilities or mental health conditions. There were 38 people living at the home on the day we inspected.

There was a registered manager for the home. 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 the previous inspection the home was rated as Requires Improvement, at this inspection we saw that the registered manager and the provider had improved the care people received and the home was rated Good. We have recommended that the provider looks at providing accessible information for people.

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 support this practice.

There were enough staff to meet people’s needs in a timely fashion and recruitment practices ensured that staff were safe to work with the people living at the home. Staff received training and support which enabled them to provide care in line with best practice guidance. Staff were kind and caring and had developed good relationships with the people they supported. People were able to make decisions about their lives and their privacy and dignity were respected.

Care plans accurately reflected people’s needs and were regularly updated. Risks to people had been identified and care was planned to keep people safe. Medicines were safely managed and people’s nutritional needs were supported. Where people needed support to eat and drink this was provided calmly and people were not rushed.

The environment was well maintained and the registered manager continued to make improvements to improve people’s experience. The home was clean and systems were in place to minimise the risk of cross infection. Staff had received infection control training and worked in line with best practice guidelines to reduce the risk of infection.

People living at the home and their relatives were confident that the registered manager was improving the care provided. The registered manager had effective systems in place to monitor the quality of care and the environment. Action was taken to resolve any concerns identified. Accidents and incidents were analysed and learning was shared with staff to reduce the risk of similar incidents in the future. People knew how to make a complaint but were encouraged to raise any concerns early so they could be resolved before a complaint was needed.

The home provides residential and nursing care for up to 40 people. People using the home may be living with a dementia, mental health issues, conditions associated with old age, physical disabilities or sensory impairments.

There was not a registered manager for the home. However, the manager had submitted an application to become registered and this was being processed. 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 carried out an unannounced comprehensive inspection of this home on 12 and 13 December 2016. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements to ensure the home was well led.

We undertook this focused inspection to check that they had followed their plan and to check if they now met legal requirements. 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 The Georgians (Boston) Limited - 50 Wide Bargate Boston on our website at www.cqc.org.uk”

At this inspection we found the provider had made all of the improvements needed to meet the regulation. Systems in place to monitor the quality of care provided were effective and the manager had taken action to gather people’s views of the care they received and used them to improve the standard of care. In addition the manager had taken notice of our last report and had taken action to identify what the latest best practice guidance said and how this should be reflected in the care they provided to people.

The home provides residential and nursing care for up to 40 people. People using the home may be living with a dementia, mental health issues, conditions associated with old age, physical disabilities or sensory impairments. There were 37 people living at the home when we inspected.

There was no registered manager for the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run. There was a new matron in place who managed the home. They had been in post for two weeks prior to the inspection. They told us they were planning to apply to the Care Quality Commission to become registered.

Our last inspection took place on 17 March 2016 we found that the provider was in breach of three regulations. People were not fully protected against the risks associated with care and risks were not fully mitigated. Staff did not receive adequate supervision and the provider did not have effective systems to assess, monitor and improve the quality of care provided or to assess, monitor and mitigate the risks to people living at the home. The provider did not act on feedback to drive and embed improvements in care. In addition to the breaches of regulation we recommended that the provider sought advice and guidance from a reputable source about supporting people to receive person centred care.

Following the inspection the provider sent us an action plan telling us about the improvements they planned to make to rectify the breaches in the regulations. At this inspection we saw that staff had received training and now supported people to move safely. In addition while formal supervisions had not always taken place in line with the provider’s policy senior staff observed the care people received and staff were confident in raising any concerns with the matron. However, we saw that there had been no improvement in the way the quality of care was monitored and people’s views on the care they received had not been gathered. 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.

Risks to people had been identified and care was planned to keep people safe. Where needed appropriate equipment had been ordered. However, risk assessments had not been reviewed in line with the timescales identified by staff. Where people had the ability to make decisions these were respected even if their decision was unwise and increased the risk of harm to the person.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. This is usually to protect themselves. The matron had ensured that where people were unable to make decisions about where they lived they were appropriately referred for a DoLS assessment. However, other areas of the mental capacity act had not been consistently applied.

There were not always enough staff available to support people’s needs in a timely manner and there was no staffing tool in place to support the decisions made around number of staff needed. In addition, the home had been using a number of agency staff and while they had ensured people’s needs were met they had not been able to provide the person centred care people received from staff who knew them well. At times staff were task focused and did not stop to consider if they supported people’s dignity.

Care plans contained the information needed to meet people’s needs safely. However, they did not contain enough information to support staff to provide person centred care and people had not been involved in planning their care. Some activities were in place but people were not fully supported to remain active and occupied.

People had been supported to take their medicines safely and in a timely fashion. People had been supported to access food and drink safely and when needed appropriate action had been take to help people maintain a healthy weight. However, at times food was not presented to support people with dementia to retain their independence.

People were not always clear on who they could complain to and while complaints had been investigated a lack of communication meant that it was not clear if people were happy with the outcome of the complaint.

The Georgians provides accommodation for 40 older people, people living with a dementia, sensory impairment or physical disability. The home provides both residential and nursing care. There were 40 people living at the home on the day of our inspection.

There was a registered manager at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider was not identifying risks to people and ensuring that people received safe care. Staff had not received appropriate supervision or support to ensure they were competent to care for people. People were not always treated with dignity and respect. Systems to monitor the quality of care received and ensure feedback from people living at the home was used to drive improvements were not effective. You can see what action we told the registered persons to take at the back of the full version of this report. We have also made a recommendation about supporting people to receive person centred care.

The registered manager had failed to create a culture where staff were encouraged to provide high quality care or to raise concerns when care was not safe or meeting people’s needs. Feedback from people living at the home was gathered through the use of questionnaires and meetings. However there was little evidence that change was implemented and embedded to drive improvements in the care people received.

The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are used to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. This is usually to protect them. The registered manager had not assessed people to ensure they were not being deprived of their liberty. Care plans recorded how people should be supported to make decisions and who they wanted to be included in the decision making process.

Staff were not always kind and considerate to people receiving care and were focused on completing tasks instead of ensuring care met people’s individual needs. Care plans did not always fully support staff to provide person centred care, to identity the risks to people and to provide safe care. In addition staff did not embed their training into the care they provided to reduce the risks for people.

Staff received an induction to the home which included appropriate training and shadowing. However, the provider did not fully support staff to access training to maintain and improve their skills. Staff were not supported with supervision from their line manager and consequently did not always provide acceptable care.

People who were able to access communal areas told us that the activities available helped to keep them entertained. However, where people chose to stay in their rooms it was less clear what support they had to ensure they were engaged and entertained.

Medicines were managed safely and people were supported to access their medicine when needed. Systems were in place to ensure medicines were ordered in a timely way and that they were always available for people. People were supported to make choices about their meals and appropriate advice was sought when people were unable to maintain a healthy weight or eat and drink safely. When needed people were able to access healthcare professionals to support them to stay healthy.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Systems were in place to make sure that the matron and staff learnt from events such as accidents, incidents and complaints. This reduced the risks to people and helped the service to continually improve.

The home had proper policies and procedure in place in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA states that every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise. The Deprivation of Liberty Safeguards are part of the MCA. They aim to make sure that people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom.

Recruitment practices was safe and thorough. No staff had been subject to disciplinary action. The matron set the staff rotas, they took people's needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure people's needs were met.

Is the service effective?

Where people did not have the ability to make a decision for themselves a best interest meeting was arranged. We saw the matron had arranged an independent advocate to represent a person who was unable to make a decision. This ensured the person's interests were fairly represented.

People's health and care needs were assessed with them. Specialist dietary, mobility and skin care needs had been identified in the care plans when required. People told us they had been involved in writing their care plans and they reflected their current needs.

Is the service caring?

People were supported by attentive staff who were able to accurately describe people's care needs. One relative told us, 'We get on ok. We are happy with the care. XXX is well looked after, I wouldn't keep her here if she wasn't.' A person living at the home said, 'On the whole I'm pretty well satisfied.'

Is the service responsive?

We saw the matron and staff worked collaboratively with other health and care professionals to ensure people received safe joined up care. We spoke with one person who told us that they had been to the hospital to see the eye doctor and then been to the opticians. Matron had arranged for the sensory impairment team to visit the person and assess their care needs around their eye sight and to put a care plan in place.

People told us that they Knew how to make a complaint. We saw the complaints log and saw the matron responded to complaints appropriately.

Is the service well-led?

The service had a quality assurance system in place; records showed that identified shortfalls were promptly addressed. As a result the quality of service was continually improving.

People were generally complimentary about the care and support they received from staff and we saw their privacy and dignity was respected.

People told us they were able to make their own choices and decisions. Where they were unable to do so we saw there were procedures in place for staff to follow. Records however, were not always in evidence to support when decisions had been made in people's best interest. This had the potential for people's rights to be overlooked.

Care records were well maintained and people or their representatives we spoke with told us they knew about them and of their rights to see them if they wished.

Medication was stored securely and people told us they received it regularly and on time. Staff practices when administering and recording the administration of medicines did not consistently ensure people's safety.

The majority of people made complimentary comments about the care provided by staff. For example, "They are first rate". Comments varied as to whether there was always sufficient staff on duty to ensure people received prompt support and care.

Personal records were stored securely, however some records had not been fully completed. This meant there was a risk people's needs may not be known and respected by staff.

At this inspection we found all senior staff members had received an appraisal and planned supervision. We saw records which confirmed this. We saw there was a plan in place for the care workers to receive their appraisals within the next month. One member of staff told us, 'Yes, I've had my appraisal with Matron; we've got new forms so we can have quite a detailed discussion. I think the meetings are ongoing at the moment.'

When we spoke with the manager we confirmed there was a rolling programme of supervisions and appraisals in place throughout the year.

We found improvements had been made towards re-writing care plans into a new format which reflected people's individual care needs more appropriately. Whilst we saw some plans had been transferred to this new style, some had still to be started.

We found there were still no recorded supervisions of staff members and an appraisal system had not been put in place. The manager assured us this would be implemented during November and December 2012.

We found improvements had been made in how the home assured itself of the quality of the services it provided. We found audits had been carried out and people who lived at the home had received questionnaires which asked for views on food, levels of comfort and dignity.

We looked at how the premises had been maintained. One person told us, 'The building is lovely, full of character. They do ever so well to keep it so clean and well decorated.'

We reviewed the policies in place to prevent the spread of infection. We found the home was kept clean and that staff observed the guidance provided to them.