Archived: St Johns Nursing Home

St Johns Nursing Home is a 'care home' which can accommodate up to 38 people in one adapted building. There were 31 older people living at the service at time of inspection, some of whom were living with dementia and/or had nursing care needs.

People’s experience of using this service:

We found that the care people received was in line with the characteristics of good in all key questions, safe, effective, caring, responsive and well led.

People were protected from risks associated with their health and the risk of suffering abuse and harm. Risks related to the environment such as fire safety were thoroughly assessed and mitigated.

Staff received appropriate training in their role. They understood people’s needs in relation to their health and wellbeing.

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.

Staff were caring in their approach and treated people with dignity.

People received individualised care, which reflected their needs and preferences.

The manager was professional and dedicated in their role. They had effective systems in place to monitor the quality and safety of the service.

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 requires improvement (published 20 October 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve in ensuring there were robust recruitments processes in place. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

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.

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

St Johns Nursing Home accommodates up to 38 people in one adapted building over two floors. There were 25 people at the service at the time of inspection. People living at the service were older persons with nursing care needs, some of whom were living with dementia.

At our last inspection in January 2018, we found widespread shortfalls within the safety and governance of the service. We identified seven breaches in six regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. The home received an overall rating of inadequate and was put in special measures.

We issued warning notices for more serious breaches of Regulations 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and requirement notices for the other regulations breached.

Following the last inspection, we met with the provider and imposed four conditions on their registration. This helped us monitor the progress of improvements made to help ensure the safety of people living at the service. The provider sent us regular action plans and audits to demonstrate how they had made and sustained required changes. We also stipulated that the provider required written permission from CQC before admitting new people to the home.

The service did not have registered manager in place at the time of our inspection. 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. Since the last inspection, the registered manager had left and no longer worked for the provider. The new manager had been in place since February 2018. At the time of inspection, their application to register as manager with CQC was in progress.

The manager had overseen significant improvements since the last inspection. The provider had met the requirements of the regulations which were breached at our last inspection.

There was a clear governance structure within the service, staff understood their roles and there was a calm and organised atmosphere in the home. The manager had implemented effective systems to oversee the quality and safety of the home. They had formulated and implemented plans to make improvements to areas which needed addressing and used audits and checks to assesses how effectively these changes had been embedded.

The provider had worked with different stakeholders to identify issues and put in place plans to make improvements. We received positive feedback from health and social care professional about how the service was managed.

People, relatives, staff and professionals told us that that the manager had instilled a positive culture at the service and that she was professional and approachable. The manager listened to complaints and feedback, using them to identify how improvements could be made.

However, we identified a breach in regulation around the provider’s recruitment processes. The provider did not always ensure that the required recruitment checks were carried out before staff started working at the service.

There were enough staff in place to meet people’s needs. The provider had recruited permanent nursing and care staff to decrease the reliance on agency workers. Staff were supported with appropriate training and ongoing support in their role.

Staff were competent and caring and understood how to provide effective care which met people’s needs. People were treated with dignity and respect and the provider had processes in place to ensure appropriate consent to care was sought.

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.

People received personalised care which reflected their preferences. The manager used a range of assessment tools to determine appropriate care and treatment plans. Care plans reflected these needs and were regularly reviewed to ensure they contained up to date information. People and their relatives were consulted about their care and told us the home was a suitable place to live in.

The provider was committed to providing compassionate end of life care to people. Staff had received training in end of life care and the manager had made arrangements for people and families to have comfortable, private spaces during people’s last days.

Risks to people were assessed and mitigated. There were clear plans in place to provide effective support around risks to people’s health and wellbeing and the environment was a safe place for people to live in. People had access to healthcare services when required.

There were safe systems in place to manage people’s medicines. People received a diet in line with their needs and preferences. Staff were attentive to people’s needs and understood how to provide comfort and reassurance to them.

People were safeguarded against the risks of abuse and harm. Staff understood their responsibility in keeping people safe and the manager had taken appropriate action when concerns arose. The manger had made CQC aware of significant events which took place in the home.

The home was a clean and hygienic environment and there were systems in place prevent the risk of infections spreading.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. However, the provider still had improvements to make in their recruitment processes and therefore the service is rated requires improvement overall.

St John’s Nursing Home 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.

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 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 in December 2016, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to send us an action plan detailing how they would make improvements in the areas of: ensuring the service obtained appropriate consent to provide people’s care, and ensuring there were sufficient numbers of trained and qualified staff in place. At this inspection we found the provider was still not meeting the requirements of these regulations and we also found concerns in other areas.

There was no clear management structure in place. The provider did not have management or supervisory staff in place who were able to assume roles in overseeing the quality and safety of the service. As a consequence, there were deficiencies in key areas of the running of the service, which resulted in the compromised safety and wellbeing of people. The registered manager had worked hard in their role to make improvements, but told us they often did not have the resources to fully implement or imbed improvements.

People’s medicines were not managed safely. The medicines management system in place did not ensure effective, ordering, storage, administration, recording or disposal of people’s medicines. This put people at risk of harm as there were examples where people received the incorrect medicines or it was not clear which medicines they were prescribed to receive.

Risks to people’s individual safety were not managed effectively to reduce the risk of harm. Systems and plans to protect people in the event of an emergency were either not completed or did not fully consider the most effective action to take in order to keep people safe. Where risks had been identified around people’s health conditions, monitoring and management plans were put in place in order to manage these conditions. However, the actions and recordings related to these plans were not always clearly followed, which resulted in confusion about the support people had received and how effective treatment plans were. There were ongoing safeguarding concerns in relation to people’s health and wellbeing which the registered manager was investigating at the time of inspection.

There were enough staff working in the home, but staffing levels were maintained only with the addition of agency staff. The registered manager told us they were in the process of recruiting staff, but the service had experienced a high turnaround of staff leaving since our last inspection. Staff’s ongoing training and development needs were not closely monitored. Many staff required training updates to ensure their knowledge was current and following best practice.

People did not always receive personalised care. Care plans did not contain sufficient detail to enable staff to understand people’s behavioural and communication needs. Handover information between staff was not always sufficiently accurate to ensure that staff had all the information required to meet people’s needs. Guidance for some people was not clear about the support they required when eating and drinking. This resulted in confusion within the staff team about the appropriate levels of support people required. People had access to healthcare services, but documentation did not always make it clear about the healthcare interventions which people required in order to promote healthier lives.

Staff did not always follow legislation to ensure they complied with legal requirements where people lacked capacity to consent to their care. Where people were unable to make specific decisions about their care and treatment, staff did not follow best practice guidance to ensure that the decisions were proportionate and in people’s best interests. The registered manager had not fully assessed or taken steps to ensure that people’s accommodation arrangements were fully supportive of their rights and freedoms. The registered manager did not always inform CQC when people had authorisations granted in relation to their accommodation when they lacked the capacity to consent to care arrangements. This was a statutory requirement.

The system of audits and quality assurance were not effective in monitoring the quality and safety of the service. Audits were completed, but they did not identify where issues around medicines or emergency equipment needed remedial action.

People were not always treated with dignity and respect. There were examples where staff not fully respectful of people’s wishes or right to privacy. People told us there was a distinction in the quality of staff between permanent and non-permanent staff, who were not always familiar with their needs. People said they were consulted about their care, but staff could take a long time to action requests.

The registered manager sought feedback from people about the service and dealt with complaints in an open and consistent way. Team meetings were used as a platform to discuss issues and make improvements, but they were not always effective in proving a catalyst to positive change.

The service was clean and there were systems in place to reduce the spread of infections. The provider had made adaptations to the building to make it suitable for people and specialist equipment was in place to support people around their health and mobility. There was a programme of activities in place, which people spoke positively about.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘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 take action 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 take action 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.”

We identified seven breaches in six regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009.

You can see what action we told the provider to take at the back of the full version of the report.

We had major concerns during our last two inspections of St John's Nursing Home and we found at these times St John's Nursing Home was providing inadequate care treatment and support .This meant the service had been placed into 'special measures' by CQC.

The owners of the service have been very responsive about putting things right and have worked cooperatively with commissioners of services to improve standards. They benefitted from support and advice provided by staff from Hampshire County Council and staff from the CCG.(Clinical Commissioning Group)

St Johns Nursing Home is registered to provide care, treatment and accommodation for up to 38 people. At the time of our visit 24 people were living there.

There was not a registered manager in post although the provider had submitted an application for two senior staff to share this role.

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 this inspection we found there had been significant improvements to the care and treatment provided to people who lived at St John's. This meant we judged St Johns was providing much better care to the people living there although we found further improvements were still needed.

Improvements needed included consistently employing sufficient numbers of staff to meet people's needs. Staff also needed to consistently enact the Mental Capacity Act 2005 to ensure they upheld people's rights. Staff had a good understanding of people's needs and the risks associated with their care but this information needed to be more consistently recorded. When people were admitted assessments had to be done in a more timely way to help to ensure staff were aware of people's care and treatment needs.

People were cared for by a dedicated and hardworking staff team who knew them well. Staff had worked very hard to improve the service and this had been recognised and appreciated by management. Staff were provided with support and training and nursing staff were given clinical supervision to ensure their professional skills were maintained.

People's nutritional needs were known and adhered to. Staff worked cooperatively with health care professionals to ensure health care needs were understood and met. The service had employed an activity coordinator which meant people had more individual and social interaction.

We carried out an unannounced comprehensive inspection of this service in April 2016 where seven regulatory breaches were identified. Following the inspection the provider wrote to us to say what they would do to meet these legal requirements. They were also working with health and social care professionals who were providing advice and support in improving the service. We met with the provider to discuss our concerns and wrote to them to provide further details about how they were failing to comply with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance. We told them they were required to become compliant with Regulation 17 by 31 July 2016.

The purpose of this focused inspection was to determine whether the provider had become compliant with Regulation 17 of the Health and Social Care Act 2008 Regulated Activities) Regulations 2014. These were the areas we had found which most compromised people’s health and safety. We will follow up all other areas of non-compliance which were detailed in our report of April 2016 at our next unannounced comprehensive inspection of the service.

St Johns Nursing Home is registered to provide care treatment and accommodation for up to 38 people. At the time of our visit 29 people were living there. There were nine double rooms. The home had a registered manager in post although they had tendered their resignation. 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.

Although overall we found the environment to be calmer with people’s requests for support answered in a more timely way, the provider continued to be in breach of Regulation 17 of the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014 as they had had not made consistent improvements to ensure people’s safety and welfare. We were not satisfied people always had enough to drink, and we were not satisfied people were protected against the risk of scalding. We did not see sufficient evidence that staff had suitable skills to care for people with diabetes or for people at risk of choking.

Staff did not manage wounds in line with NICE (National Institute for Health and Care Excellence) guidance and there were no validated pain assessments in place to ensure people received pain relief when they needed it.

Our previous inspection had taken place in January 2015. At this time we judged overall that the service required improvement before it could demonstrate it provided consistently safe, effective, caring and responsive care. As a result of shortfalls in all these areas we concluded that they also needed to make improvements in the leadership of the home. We said there were two breaches in legislation, these related to the management of medicines and systems and processes relating to good governance. At this inspection we found the required improvements had not been made and there were other shortfalls which also constituted breaches in regulation. These related to the way the service safeguarded people from possible abuse or neglect, the way in which they identified and managed risks, particularly to people's health, and the way they gained people’s consent to their care and treatment. We found staffing levels were not always adequate to meet people’s needs. Some elements of the delivery of service were task centred which had an impact upon how well the service could demonstrate it was providing care which always met the needs and preferences of the people living at St John's.

St Johns Nursing Home is registered to provide care treatment and accommodation for up to 38 people. At the time of our visit 36 people were living there. There were 9 double rooms. Since our last inspection a new registered manager had been employed.

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. The registered manager was not a nurse. She was supported by a registered nurse who was head of clinical Care. The registered manager demonstrated that had understood some of the shortfalls within the home but action taken had yet to have an impact upon the overall quality of the service.

Some people were happy with the quality of care and support they were being provided with and health care professionals and relatives all provided positive feedback when they were surveyed about the quality of care and treatment people received. The complaints procedure had improved.

We witnessed some kind and caring interaction between staff and people who lived at the service. However the service continued to have significant shortfalls which at times put people at avoidable risk. You can see what action we told the provider to take at the back of the full version of the report.

Special measures.

The rating for this service is 'inadequate'. This means that the service has been placed into 'special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location or cancel the provider's registration.

People had care plans in place which showed the care and support each person needed. We spoke with staff who were clear about individual needs and how they supported people. The provider sought people's views and action was taken to improve the service provided.

The provider did not have an up to date infection control policy and the laundry room lacked the facilities to minimise the risk of infection. People received their medication as prescribed but we found some medication was not stored securely. The complaints procedure displayed was out of date and gave incorrect information about how to complain.

We looked at how the medication was audited with regard to stock numbers for three people. Records matched the numbers of tablets accurately for one person but not the other two.

Used needles were not stored safely, although they were locked away from people living in the home.

We found St John's Nursing Home was not compliant with this outcome.