Archived: St Michael's - Care Home with Nursing Physical Disabilities

St Michael's - Care Home with Nursing Physical Disabilities is a nursing home providing personal and nursing care for up to 36 people. The service provides support to people with complex neurological and physical disabilities. At the time of our inspection, there were 20 people using the service. The building is a large period building with a sizeable communal dining area. There is a physiotherapy room on site.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and/or who are autistic.

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

Right Support, Right Care and Right Culture

The provider did not always have oversight of the service; there were inconsistencies in the recording of people’s information, which meant people were not always getting good quality and safe care. There was mixed feedback from staff about how safe they felt the service was. Staff training had improved since our last inspection; although there were still concerns with how well people were cared for, there was a plan in place for nursing staff to have their competencies reviewed. We observed positive interactions between staff and people.

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

Rating at last inspection

The last rating for this service was inadequate (published 06 June 2022). A targeted inspection took place on 20 June, the service was not rated from that inspection.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notices we previously served in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains Inadequate.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement and Recommendations

We have identified continued breaches in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good Governance)

Please see the action we have told the provider to take at the end of this report.

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 follow our enforcement procedures.

Special Measures

The overall rating for this service remains ‘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 time frame 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 of 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.

St Michael’s - Care Home with Nursing Physical Disabilities is a nursing home providing personal and nursing care to up to 36 people. The service provides support to people with physical disabilities, nursing needs and people with a learning disability and autistic people. The building is a large period building with a communal dining area. There is a physiotherapy room on site. At the time of our inspection, there were 20 people using the service.

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

This was a targeted inspection considering the assessment, monitoring and management of choking risks to people with eating and drinking needs.

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support, Right Care and Right Culture

The provider did not always have oversight of the quality of care and safety around the risks of people choking. The provider and registered manager had not always ensured people received safe or good quality care. This put some people's safety at risk and meant people did not always receive a safe service. Not everyone had up to date information in their care plans about their eating and drinking needs. Not all risks were being identified, and where they were, this was not always updated in care plans and risk assessments for staff to read. Handover information shared between staff did not accurately reflect changes to people’s needs. No one else had come to harm because of this. We observed positive interactions at mealtimes with staff and people.

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

Rating at last inspection:

The last rating for this service was Inadequate (published 6 June 2023). At the time of this Inspection, the provider had not produced an action plan to show what they would do and by when, to improve the service. The service remains inadequate and is in special measures.

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the assessing, monitoring and management of risk of choking for other people living at the service. This inspection examined those risks.

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

Enforcement

We have identified breaches in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan specifically around risk of choking to people with identified eating and drinking needs from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor the information we receive about the service, which will help inform us when we next inspect.

St Michael’s care home with physical disabilities is a nursing home providing personal and nursing care for up to 36 people. The service provides support to people with complex neurological and physical disabilities. At the time of our inspection there were 27 people using the service.

The building is a large period building, with a large communal dining area. There is a physiotherapy room on site.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people and providers must have regard to it.

Based on our review of the key questions safe, responsive and well-led, the service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right Support:

The provider failed to have oversight of the quality of care and safety. The provider and registered manager had not ensured people received safe or good quality care. This put people's safety at risk and meant people did not receive a safe service.

The service did not always give people care and support in a safe, clean and well-maintained environment.

People were not always able to pursue their chosen interests and achieve their goals because of staffing shortages at the service. The home was reliant on agency staff that did not always know people well. Staff did not always communicate with people in a way that met their needs.

People had some choice over their living environment and rooms were somewhat personalised.

Staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice

Right Care

People were not always protected from abuse or the risk of harm; not all staff had completed necessary training to meet the needs of the service user, staff did not always recognise risk of harm to people, staff did not always escalate concerns as required, audits and monitoring of the service did not always identify risk and reoccurring concerns. An effective system was not in place for reporting and reviewing accidents, incidents and near misses involving people.

People's medicines were not always safely managed, this meant people were at risk of receiving or not receiving medicines which may not meet their current needs.

Health and social care professionals were involved in the care and support of the people living in the home.

Right Culture

There were not enough staff and there was a reliance on agency staff to meet people’s needs.

The provider and the manager had failed to implement a robust system to monitor the quality of the service. Improvement in areas of risk management had not been fully implemented in respect of the people’s safety and cleanliness. The geographic location of the service was isolated, the home being on a main road. There was no access to public transport nearby. The service had a vehicle to take people to appointments and on trips.

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

Rating at last inspection

The last rating for this service was outstanding (published 6 November 2019)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We have found evidence that the provider needs to make improvements. Please see the safe, responsive and well-led sections of this full report.

The overall rating for the service has changed from Outstanding to Inadequate based on the findings of this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Michael’s on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, person centred care, safeguarding, safe staffing and good governance at this inspection.

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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

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

St Michael’s – Care Home with Nursing Physical Disabilities is a residential care home providing personal and nursing care for 34 people with physical disabilities at the time of the inspection. Most people had complex needs as well as the physical disability and some lacked the ability to verbally communicate with us. The service can support up to 36 people. One person was on a short stay placement at the home.

The home is a large, period building over three floors with spacious grounds. There were numerous communal spaces throughout the home including a chapel, dining room and lounges. There was also a physiotherapy area including an indoor gym.

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

People received incredibly responsive care. There was a drive to access pilot schemes and find ways to innovate the support people received. There was a strong emphasis on hydration and nutrition being embedded throughout the home. These provided opportunities for people’s control, including what they ate and encouraged healthier lives. People told us how much healthier they felt since participating in this and were celebrating losing weight.

The home was managed by a registered manager who strove to provide people with bespoke care in a warm, open environment. The provider supported the registered manager to achieve these goals. People, relatives and staff told us the registered manager was excellent and had ensured the best care and support was provided. There was a constant drive for continuous professional development to ensure staff provided the best care possible. Staff at all levels felt supported and were proud of their work to improve the lives for people which had been recognised. They often went above and beyond to enrich experiences and value the people.The registered manager and provider continually monitored the quality of the service and made improvements in accordance with people’s changing needs.

People received exceptionally good care from staff who treated them like part of their extended family and knew them incredibly well. They had found ways to involve people in all decisions about their care and home. Feedback from people, relatives and visitors to the home informed us about how well cared for they felt. Care and support was incredibly personalised to each person, which ensured they were able to make choices about their day to day lives in line with their needs, hobbies and interests. At all times, independence was promoted and ways for people to take ownership of their home. Information about their preferences were gathered in detail by members of staff and care plans were incredibly personalised.

People’s privacy and dignity was respected by staff and their cultural or religious needs were valued. People, or their representatives, were involved in decisions about the care and support they received. People who had specific end of life wishes had their preferences facilitated by staff to help provide a very dignified death. Their relatives were supported throughout and after the person’s death.

The service provided to people was responsive to people’s individual needs. The registered manager was passionate in leading a team of staff to promote personalised activities. Staff responsible for organising activities had listened to every person’s wishes and needs so they could develop bespoke opportunities to enrich their lives. Activities always considered people’s hobbies and interests and were personalised as much as possible.

There were volunteers who regularly came and supported people. They ran activities and felt a valued part of the community which the provider and management were promoting. Complaints were fully investigated and responded to in a timely manner. The registered manager had a strong ethos of valuing any concern a person or their relative raised because they knew how important it was for them.

There were suitable numbers of staff to meet people’s needs. Interactions were on a personal level and not just task based. Risk assessments were carried out to enable people to retain their independence and receive care with minimum risk to themselves or others. People received their medicines safely. People were protected from abuse because staff understood how to keep them safe and were sure action would be taken if any concerns were raised.

The home continued to ensure people received effective care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People who required special diets had their needs met and meal times were treated as a social opportunity. Staff had the skills and knowledge required to effectively support people. People told us their healthcare needs were met and staff supported them to attend appointments.

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

Rating at last inspection

The last rating for this service was good (published 16 December 2016)

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Michael’s – Care Home with Nursing Physical Disabilities on our website at www.cqc.org.uk.

This inspection was unannounced and took place on 17 and 18 August 2016.

The home had a registered manager. 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 and relatives told us they felt safe. Most of the medication procedures in the home were safe but there was a risk staff would not know where guidance was for people who needed medicines ‘as required’. Medicines were stored safely.

People who required special diets received them and staff understood about special diets to meet people’s care and health needs. But one person was found with an un-thickened drink which led them to cough and had not been given the option to have it thickened.

Staff were supervised and received enough training to meet people’s needs.

A safe recruitment procedure was in place and staff received checks before starting to work with people.

Staff knew how to recognise and report abuse. They had received training in safeguarding adults from abuse and knew the procedures to follow if they had concerns.

There were sufficient staff available to enable people to take part in a range of activities according to their interests and preferences. The registered manager was currently recruiting more staff because they had identified people’s needs were changing.

People's health care needs were monitored and met. The home made sure people saw the health and social care professionals they needed and implemented any recommendations made which people agreed to.

Staff and the registered manager had understanding about people who lacked capacity to make decisions for themselves. However, some people had not had their records updated when they lacked capacity to be in line with the code of practice. Staff understood about Deprivation of Liberty Safeguards (DoLS) and the process to follow to make sure people’s human rights were respected.

Staff supported and respected the choices made by people. People’s diversity was respected. People had a choice of meals, snacks and drinks, which they told us they enjoyed.

People and their relatives thought the staff were kind and caring and we observed positive interactions. People’s privacy and dignity was respected.

Staff had good knowledge about people’s needs. Their care plans had met national standards for end of life care which helped to ensure best practice for people when nearing the end of their life. The needs of the people were reflected in their care plans.

Some audits were being completed by the registered manager and provider to identify shortfalls. They had both recognised further improvements were required to make the audits more comprehensive. When shortfalls had been identified the registered manager resolved them. There were systems in place to manage complaints and the registered manager demonstrated a good understanding of how to respond to them.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe. Safeguarding procedures were robust and staff understood how to safeguard the people they supported.

People felt safe because their rights and dignity were respected and they were involved in making decisions about any risks they may take. When people were at risk, staff followed effective risk management policies and procedures to protect them.

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

The home had policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people were protected from discrimination and their human rights were protected.

Is the service effective?

There was an advocacy service available if people needed it, this meant that when required people could access additional support.

Care plans reflected people's current individual needs, choices and preferences. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with physical impairments. People had access to appropriate space to see and look after their visitors, for activities, to spend time together or to be alone.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, 'I love living here, this is my home', 'All my friends are here', 'I love it here'.

People using the service and staff completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. Appropriate professionals were involved in planning, management and decision making.

Is the service responsive?

Where appropriate, a person's capacity was considered under the Mental Capacity Act. When a person did not have capacity, decisions were always made in their best interests. Advocacy support was provided when needed.

People completed a range of activities in and outside the service regularly. The home had its own adapted minibus, which helped to keep people involved with their local community.

People knew how to make a complaint if they were unhappy. One person had made a complaint and changes had been made as a result. People can therefore be assured that complaints are investigated and action is taken as necessary. People we spoke with felt confident to express any concerns or complaints about the service they received.

Is the service well-led?

There was a registered manager in post and all other conditions of registration were met.

The service worked well with other agencies and services to make sure people received their care in a joined up way. The service worked in partnership with key organisations, including the local authority and safeguarding teams, to support care provision and service development.

The service had a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Robust quality assurance and governance systems were in place and used to drive continuous improvement.

Concerns and complaints were used as an opportunity for learning or improvement.

People who lived in the home and visiting relatives were very complimentary about the care provided. One person who lived in the home said 'I'm looked after marvellously, it's great. There's so much to do and so many outdoor activities'. Another person said 'This is a first class home. All the staff work so hard to produce a good result for us'.

The home looked generally clean and reasonably well maintained. Systems were in place to reduce the risk and spread of infection. However, some parts of the home were shabby and in need of refurbishment.

People told us they received the correct medication at the right times of day. One person said 'The nurse always comes to my room at the right time to give me my medicines'. Another person said 'I always have my medicines with my meals'. One person's visiting relative said 'The nurse always brings the medication every lunch time without fail'.

People who lived in the home and their relatives said there was enough staff to care for people's needs. People said they were well looked after and staff usually responded quickly when needed.

We found the provider had effective systems in place to monitor the quality of service and to manage potential risks to people's health and safety.

There was always at least one trained nurse on duty who was responsible for ensuring that people's clinical needs were met. One visiting healthcare professional told us they felt the home provided a high standard of nursing care. They said staff involved other healthcare professionals when necessary and in a timely manner.

We saw people who liked to spend time in their personal rooms had access to a call bell. People said if they rang their bell for assistance staff responded quickly. Throughout the day we noted call bells were answered very promptly meaning that people did not have to wait for assistance.

All of the areas of the home we saw were clean and fresh. One member of staff took a lead role in ensuring that infection control policies and procedures were kept up to date. People who lived at the home told us they would be comfortable to talk with a member of staff if they had a concern. One person said "I would always speak with the manager, there's no need to worry about things".