Archived: St Nicholas Care Home

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

At this inspection we found a continuation of failings at this service. Sufficient action had still not been taken to address the seven breaches of the regulations we found at our previous inspections in November 2018 and May 2019. At this inspection in November 2019, we found an additional breach of the regulations.

This will be the third consecutive inspection that this service will be rated as inadequate overall.

The provider had not ensured the manager for the service had registered with us as is required and there continued to be a lack of oversight of the service from the provider. Governance systems remained ineffective at identifying shortfalls within the service and improvements noted by relatives had not been actioned.

Risks relating to people’s health and wellbeing had not always been identified or plans put in place to mitigate these risks. People were not supported to maintain an adequate intake of food and fluid.

Staff practice relating to infection control remained poor and there continued to be several environmental risks identified in the home that had not been managed well.

Reviews of accidents and incidents remained poor and investigations to learn lessons from incidents did not take place. The provider continued not to report notifiable incidents.

We found an additional breach of the regulations. This was because the provider failed to report a safeguarding incident to the local authority and thoroughly investigate the concerns.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People continued to receive care that did not always uphold their dignity or respect their privacy.

Records of people’s care still lacked person-centred detail and were not reflective of people’s most current needs.

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 rating for this service was inadequate (published 26 July 2019) and there were multiple breaches of regulation. At this inspection we found sufficient improvements had not been made, and the provider remained in breach of seven regulations. We also found one new breach relating to safeguarding people from abuse and improper treatment.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 14 May 2019. Breaches of legal requirements were found in relation to safe care and treatment, good governance, meeting nutritional and hydration needs, need for consent, person-centred care, dignity and respect and notification of other incidents.

We undertook this focused inspection to check the provider had now met the legal requirements. This report only covers our findings in relation to the key lines of enquiry which relate to those requirements.

The ratings from the previous comprehensive inspection for those key lines of enquiry not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service is inadequate. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to safe care and treatment, good governance, need for consent, person-centred care, dignity and respect, meeting nutritional and hydration needs, safeguarding people from abuse and notification of other incidents.

CQC used its powers to keep people safe, and a Notice of Proposal to vary a condition on the Registered Provider's registration, to prevent the regulated activity being carried on at St Nicholas Care Home, was sent to the Registered Provider on 18 January 2019. On 26 March 2019 the Notice of Decision was sent to the Registered Provider advising that we had decided to adopt the proposal to vary a condition on their registration.

The Registered Provider appealed against this decision to the First Tier Tribunal (Care Standards) under section 32 (1)(b) of the Health and Social Care Act 2008. The appeal hearing was held on 9, 10, 11, 12 and 13 December 2019, and the decision was made that CQC's action "was both necessary and proportionate." The appeal was dismissed by the tribunal judge and CQC was informed of this decision on 22 January 2020. This means that the Registered Provider can no longer provide any regulated activities at St Nicholas Care Home and the service is now closed.

Following the Tribunals decision, the local authority took swift action to ensure that all people living in the service were supported to move to alternative accommodation. The last person moved out on 24 January 2020.

This service is therefore no longer in operation.

About the service: St Nicholas is a residential care home that was providing accommodation and personal care to 15 people aged 65 and over at the time of the inspection.

People’s experience of using this service:

After our inspection in November 2018, the provider sent us an action plan detailing what improvements they intended to make to achieve compliance with the regulations. They stated that all actions would be completed by 31 January 2019.

We found a continuation of widespread failings across the service. The provider had not taken sufficient action to address the six breaches of the regulations found at our last inspection. At this inspection we found a further breach of the regulations. Therefore, the provider is now in breach of seven of the regulations.

The unstable leadership and lack of oversight from the provider meant there were not effective systems in place to monitor and assess the quality of service being delivered. Audits carried out were ineffective in identifying and mitigating risks in relation to the health and safety of people using the service.

People were not invited to provide feedback about the service but their relatives and staff were asked to complete a satisfaction survey. The provider had not reviewed the responses. This meant any shortfalls identified in the responses had not been addressed. There was also a lack of action taken when audits identified shortfalls in the quality of service being delivered.

Individual risks to people’s health, wellbeing and safety were not adequately planned for or mitigated. People were not supported to maintain a healthy intake of food and fluid.

A number of risks found within the environment were found which the provider had failed to identify through their checks of the service. There were poor infection control procedures.

The provider failed to adequately review accidents and incidents and learn lessons from poor practice. They also failed to notify the Commission of all notifiable incidents.

Staff did not work in line with the principles of the Mental Capacity Act 2005. Assessments of people’s capacity were generic and there was a lack of consideration given to maximising people’s ability to make decisions.

People were not cared for in a way that upheld their dignity and privacy.

People’s care records were not person-centred and did not detail their most current needs.

Medicines were managed and administered in a safe way.

Staff felt supported in their role and attended regular staff meetings.

Rating at last inspection: The service was rated inadequate at the last inspection and remained in special measures. The report was published on 22 January 2019.

Following the last inspection, we sent an urgent action letter to the provider telling them about our findings and the seriousness of our concerns. We asked them to complete an urgent action plan telling us what they would do and by when to improve the key questions of safe, effective, caring, responsive and well-led to at least ‘Good.’ We took immediate enforcement action to stop further admissions to the service.

Why we inspected: We inspected on 14 May 2019 because the home was in special measures which means we must return within six months to check the service again.

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: The overall rating for this service is inadequate and the service therefore remains 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.

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

A new manager had been appointed in September 2018 and they were in the process of applying to become 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.

We found the provider failed to comply with six of the regulations as required under the HSCA 2008 (Regulated Activities) Regulations 2014. The provider continued to fail to make and sustain improvements within the service. After this inspection we asked the provider what immediate action they would take in response to the concerns we found. They provided us with an action plan which detailed the action they would be taking to ensure the safety of people living in the home.

During this inspection we found that good practice had not been maintained in relation to the safe management of people’s medicines. Administration records for people’s medicines were not complete and medicines stored within the service were not accurately accounted for.

Risk assessments for people’s individual care needs were not accurate and lacked detail. There were no environmental risk assessments for different areas of the home. Personal emergency evacuation plans for people did not accurately reflect the support they required to evacuate the building in the event of a fire. Therefore, there were insufficient measures in place to identify, manage and mitigate risks both to people and within the environment.

Some areas of the home were not clean and staff did not follow guidance to protect people from the risk of infection as they did not always wear the correct personal protective equipment.

Safeguarding incidents had not been identified and reported to the appropriate authorities. Accidents and incidents were not fully documented and follow up of people’s health and wellbeing post incident did not take place.

There were not enough staff to be responsive to people’s needs and to ensure their safety was maintained. These findings meant that the provider remained in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were not involved in day to day decisions about their care and treatment and staff lacked knowledge about the importance and guidance around making a decision in a person’s best interest. Where people were deprived of their liberty, records relating to this had been not completed in line with the Mental Capacity Act 2005. Therefore, the provider remained in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff did not support people to maintain a healthy nutritional intake and did not follow health professional’s guidance relating to people’s food and fluid intake. This meant the provider remained in breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider remained in breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people were not treated with respect and their dignity was not upheld. Staff did not have enough time to spend with people other than when they were performing care tasks.

People’s care plans and associated records did not detail their most current care needs and some documents had not been reviewed. Where records had been reviewed, this process was not thorough and did not identify any changes.

Staff were not adequately deployed to ensure they remained responsive to people’s needs. Therefore, the provider remained in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was a lack of processes in place to monitor and assess the quality of service being delivered. Systems that were in place were not robust and did not identify shortfalls within the service and drive improvement. This meant that the provider was still in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Assessment of people’s care needs had improved and the manager went to visit people in hospital to assess their needs.

Staff completed an induction when they started work at the service and all staff received supervision with the manager. Staff did not receive training specific to people’s individual care needs.

People had access to healthcare professionals when needed.

Staff enjoyed their work and felt supported by the manager in their role.

The overall rating for this service is ‘inadequate’. Therefore, the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections.

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.”

St Nicholas Care Home is registered to accommodate a maximum of 39 people, some of whom may be living with dementia. There were 12 people using the service when we inspected. The care home is one large adapted building, with bedrooms arranged over two floors and a number of communal areas.

We inspected on 5 and 6 February 2018 and the first day of our inspection was unannounced.

A new manager had been appointed at the service in November 2017 and was in the process of becoming registered with CQC. 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 (HSCA) 2008 and associated Regulations about how the service is run.

During this inspection, we found that the provider was in breach of seven regulations. You can see what action we told the provider to take at the back of the full version of this report.

The provider had failed to comply with a number of the regulations as required under the HSCA 2008 (Regulated Activities) Regulations 2014. In addition, the provider had consistently failed to sustain improvements where breaches of regulations had been identified during previous inspections.

We found that sufficient improvements had been made with regard to the safe storage, administration and management of medicines. However, there were still shortfalls in other areas relating to people’s safety, which meant the provider was still in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Systems to monitor the service were not accurate or effective, which meant the provider was still in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Where people lacked the mental capacity to make a specific decision, the provider had not made sufficient improvements to act in accordance with the requirements of the Mental Capacity Act 2005. Therefore the provider was still in breach regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Improvements were still required in respect of providing person-centred care and records relating to people’s care were still not consistently written in a person-centred way. Therefore the provider was still in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that that people’s dignity was not consistently ensured and people were not always treated with respect. The provider was found to be in breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People’s nutritional and hydration needs of people were not always being met. The provider was found to be in breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Individual risks to people were identified but risks assessments were not always in place for known risks or, those that were in place, did not always contain sufficient detail about how to manage the risk. Risks within the environment were also not always managed and mitigated.

The provider had a business continuity plan which detailed what should be done in an adverse event such as loss of utilities or fire. People living in the home also had personal emergency evacuation plans in place.

There were mixed feelings regarding staffing levels, particularly around mealtimes, and staff were not always deployed appropriately.

Some staff training updates were overdue, although the manager took action, when prompted, to ensure the required updates were arranged for staff to complete. The service did not always follow robust recruitment procedures to ensure only staff suitable to work in care were employed.

Some aspects of the home were not always clean and staff did not always wear the correct personal protective clothing when attending to people’s personal care and hygiene needs.

Assessments of people’s needs took place before they moved into the home. Assessments did not all contain sufficient detail and some sections of the assessment form had not been completed.

Accidents and incidents were recorded appropriately and records showed what action was taken immediately after the accident or incident. Appropriate and timely referrals were made to relevant healthcare professionals and these professionals were involved in people’s care where necessary. People’s preferences regarding the care they wanted at the end of their life were documented in their care records.

Staff missed opportunities to speak and interact with people because their approach was more task led than person-centred. People were not always spoken to according to their needs and staff did not always treat people in an empathic way.

People’s relatives were welcome and there were no restrictions on when they could visit the home. People were able to maintain relationships that were important to them and were supported to avoid isolation. People were also able to follow their individual interests, hobbies and activities.

There were regular meetings for people who lived in the home, which provided opportunities to have a say about how the service was run and offer feedback to the manager and staff. Staff meetings were also held regularly. These gave staff the chance to put forward any suggestions about what they could do to improve the service and discuss what processes were not working so well. There was a complaints policy in place and complaints were investigated and dealt with in a timely manner.

Staff, people using the service and their relatives told us that the manager was motivated, caring and visible. We acknowledged that the manager had made improvements in areas such as medicines and there was some work-in-progress in other areas such as care plans. However, we concluded that the manager was not receiving sufficient oversight and support from the provider, to enable them to complete and sustain all the improvement actions required. This was shown by the continued breaches identified during this inspection.

At this inspection we found there had been insufficient improvements made and some improvements had not been sustained. This resulted in the service being rated inadequate in well-led.

The overall rating for this service is ‘Requires improvement’. Therefore the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections.

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.”

St Nicholas Nursing Home is not a nursing home and does not provide nursing care to people. The provider has not amended the name of their service on their registration since they ceased to provide nursing care. St Nicholas’ provides accommodation and care for up to 39 people, some of whom may be living with dementia. At the time of our inspection visit 13 people were living in 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. There was not a registered manager in post, however a manager was in the process of registering with CQC and will be referred to as ‘manager’ throughout this report. The providers had also employed a consultant to support them in making improvements to the home. Both were present during the inspection.

At our inspection on 30 January and 1 February 2017 we found breaches of nine regulations. We found serious and widespread concerns. There were significant shortfalls in the care and service provided to people. During this inspection on 19 June 2017, we found whilst improvements to the service had been made the provider was still in breach of four regulations. You can see what action we told the provider to take at the back of the full version of this report.

The management and leadership were improving however it had not yet been sustained over a period of time. Systems had not yet been implemented to monitor the service, and therefore we could not judge their effectiveness and sustainability. Some issues which we found previously in our inspection in January and February 2017 had not been fully resolved. Therefore the provider was still in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, concerns had been identified and the manager had worked closely with the external consultant to devise and begin to implement a suitable action plan in order to resolve the concerns associated with this service.

There was not always adequate guidance in place for staff to administer medicines to ensure they were not used inappropriately. Improvements were needed to the risk assessment of medicines people administered themselves, and oversight of medicines administration. This meant the provider remained in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People did not always receive care that was individualised and met their specific health needs, and staff had not always followed recommendations from healthcare professionals. This meant that the provider remained in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff had not always fully assessed people’s capacity to make specific decisions, and recorded how decisions had been made in people’s best interests. This meant that the provider was still in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risks to people’s welfare had not always been identified. Risk assessments were sometimes generic and not specific to individuals. There was not always clear guidance provided to staff about how to mitigate risks to people. However, we found at this inspection that the management of some risks had improved and staff were aware of risks to individual people and how to manage these.

Staff had received further training and supervision and there were enough staff to meet people’s needs. Staff delivered compassionate care to people and there were enough of them to meet people’s needs safely.

Improvements had been made to the housekeeping procedures and the home was cleaner, however further improvements were still required.

People were positive about the food they received and there was choice available. Drinks were made available to people throughout the day.

The overall rating for this service following our inspection in January and February 2017 was ‘Inadequate’ and the service was therefore in ‘special measures’. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

At this inspection in June 2017, we found that the service had made improvements and the overall rating has changed to Requires Improvement.. However, the service remains inadequate in well-led. This means that the service remains 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.

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 Nicholas Nursing Home is not a nursing home and does not provide nursing care to people. The provider has not amended the name of their service on their registration since they ceased to provide nursing care. St Nicholas’ provides accommodation and care for up to 39 people, some of whom may be living with dementia. At the time of our inspection visit 21 people were living in the home, with two people in hospital.

A registered manager was in post. They were in the process of handing over the management of the service to a new manager who was in post as the acting manager. Both were present during the inspection. The registered manager told us that they are at the service most days in the week. They had been promoted to the role of operations manager for the provider who has five services in total. An acting manager was in post and was being trained with a view to applying for registration as the 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.

This inspection found breaches of nine regulations. We found serious and widespread concerns at this service. There were significant shortfalls in the care and service provided to people.

Risks to people’s welfare had not always been identified. Risk assessments were sometimes generic and not specific to individuals. There was not always clear guidance provided to staff about how to mitigate risks to people.

We observed poor practice that put people’s safety and wellbeing at risk. Whilst records showed that staff had received training it was either not being put into practice or the training was not of a suitable standard.

On occasions people were not always referred to healthcare professionals when necessary and staff had failed to implement guidance they had received from healthcare professionals.

There were not enough care staff on duty to keep people safe or to meet their needs in a timely way. There was not enough housekeeping time allocated to ensure the home was kept clean at all times. There was not enough laundry time allocated to ensure that people’s clothing was effectively laundered.

People were positive about the food they received. However, we were concerned that some people, who required higher levels of support with their meals, did not receive this. Relatives and health professionals had also raised concerns about people not being supported with eating and drinking.

In their direct dealings with people we saw that most staff were kind and caring. However, some staff didn’t engage appropriately with people. We found practices in the home which showed a lack of respect and compassion for the people who lived there. People were not receiving person centred care which met their needs or preferences.

We found there was a lack of effective management and leadership. This coupled with ineffective quality assurance systems meant that the issues we found had not been identified or resolved.

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.

The purpose of this inspection was to establish whether improvements had been made as a result of the findings from previous inspections. These had been carried out on 14 and 18 March 2014 and 8 May 2014. We were satisfied that improvements had been made.

We reviewed the evidence we had obtained during our inspection and used this to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

Our May 2014 inspection identified that improvements had been made to the staff numbers on duty, but that these improvements had not been sustained. This inspection established that, although there had been in the odd occasion when staff numbers were below the required amount, this had not been a frequent occurrence. Consequently, improved and sustained staffing numbers had resulted in better care for people living in the home.

During the May 2014 inspection we found that several areas of the home had not been adequately cleaned. This presented cross contamination risks as well as an unpleasant environment for people to live and work in. Infection control audits had been carried out by the local authority on 19 May 2014 and 01 July 2014. The service had made substantial improvements in response to these audits and our inspection. This meant that the risks of cross contamination and the spread of infection had been reduced.

Since our March 2014 inspection action had been taken to improve the environment for people living at St Nicholas Nursing Home. During this inspection we noted people making use of improved garden areas in the nice weather. The laundry had been refurbished which had resulted in a more pleasant and hygienic working environment for staff.

We discussed the potential implications to the service of the recent Supreme Court judgement relating to the Deprivation of Liberty Safeguards (DoLS) with the manager. These safeguards form part of the Mental Capacity Act 2005 and make sure that people are looked after in a way that does not inappropriately restrict their freedom. The provider may find it helpful to note that the manager was unable to find an organisational policy which covered DoLS. As a result of our discussion the manager submitted DoLS applications to the local authority in respect of two people living in St Nicholas Nursing Home. However, the wider issues in relation to DoLS needed to be addressed corporately by the provider.

Is the service effective?

People's nutrition and hydration needs were well supported. People received sufficient fluids to ensure they were hydrated. We saw assessments of people's dietary needs and where special diets were advised by health care professionals, these were provided.

People told us that they were happy with the care that they received and that their needs were being met by the service. The care plans we reviewed had been re-written in recent months. We noted that these contained a better focus about how people's emotional and social needs were to be met.

Is the service caring?

People were supported by kind and attentive staff. Staff demonstrated patience and provided encouragement to people who required a little gentle prompting, for example, to encourage them to eat more. The cook made every effort to provide alternative meals for people who didn't want either of the meal options offered.

We saw from responses to a recent survey that one person had stayed at the home for two weeks respite care. They had stated, 'My two week stay was very pleasant and therapeutic.' Another quote we saw said, 'There have been some significant recent improvements. The current staff are generally very good and caring.' People we spoke with were positive about the care given by the staff.

Is the service responsive?

Where the service felt that improvements could be made action was taken. For example, the service was in the process of changing its pharmacy and medication support arrangements. This was because the change would result in a more frequent prescription delivery service to the home and more pharmacy support visits. Due to on-going issues with the current grocery delivery arrangements alternative options were being explored.

Work had been undertaken to streamline improvements to people's care plans and improve the care people received. Changes had been made around record keeping for wound care and nutritional screening assessments. Clearer systems were in now in place to record and monitor people's nutritional intake and re-positioning requirements. These changes meant that staff were able to identify, quickly and easily, whether people were being appropriately monitored so they could take action as necessary.

Is the service well led?

We were advised by the manager that the provider had recently recruited a Quality and Compliance Manager who was due to start in the next few weeks. Their role would be to lead on compliance and quality issues across the provider's portfolio of homes. They would work alongside service managers to identify and implement solutions to raise service performance.

The service had systems in place to ensure that people's care and support was monitored and reviewed for effectiveness.

A further inspection will be carried out in coming months to establish what progress has been made in other areas outstanding from the March inspection and to follow up concerns identified during this inspection. People's views will be required to support this next inspection.

We reviewed the evidence we had obtained during this inspection and used this to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

We were satisfied that substantial progress had been made in ensuring that people's care was delivered in accordance with their care plans. Risks to people's health were appropriately managed by staff.

The service had increased the care staff number by one for both daytime shifts. Currently the service wasn't always able to sustain this number of staff on duty because the pool of staff available was insufficient. Further care staff were due to commence duties soon. However, we were satisfied that the provider had taken action to increase the number of staff on duty to better meet people's needs.

During this inspection we spent time looking around the premises. We found that several areas of the home had not been adequately cleaned which put people at unnecessary risk of cross infection. The manager and provider agreed that these areas needed prompt attention.

Is the service effective?

We found from reviewing people's care records that where concerns to their welfare had been identified, advice was sought from various healthcare professionals. We noted the involvement of several health specialists including physiotherapists, speech and language therapists, dieticians, and the community mental health team. People could be sure that when necessary, staff would obtain the services of other health professionals to ensure their welfare.

Is the service caring?

Throughout our inspection we observed staff speaking with people in a supportive, relaxed and friendly manner. We noted one staff member gently re-assuring one person who had become anxious. The staff member had sat with the person to be at the same level as them, touched their arm, smiled and spoke calmly with them. This person soon settled as a result of this intervention.

Is the service responsive?

The service had made organisational changes to better support the needs of people living the home. Night staff duties had changed which allowed morning staff a bit more time to get people up and out of bed if they wished. We had previously been told by some relatives that their family members hadn't been ready to go out when they arrived at the home. During this inspection one relative telephoned with a request for their family member to be ready for a particular time later that day. This was carried out promptly.

Improved staffing levels will reflect favourably on the service's ability to respond to people's needs. On the day of our inspection six care staff were on duty. We noted that staff were busy, but not overly rushed as we had seen on previous occasions when there had been fewer staff.

Is the service well led?

We observed that new arrangements to have senior care staff co-ordinating and organising the shifts were working well. A third senior carer was due to join the service in June.

We spoke with the provider, the manager and the deputy manager as part of this inspection. They told us they were committed to improving the service.

We found that there were significant staff shortages. People who had been assessed as needing one-to-one care did not receive it. For most of the time there was one carer for two people who had each been assessed as requiring one-to-one care. Sometimes this carer needed to observe other people as well. Staff were struggling to cope in the delivery of personal care to people, particularly in the mornings.

When reviewing people's care plans we found significant shortcomings in relation to maintaining people's fluid levels, repositioning requirements and nutritional screening. This meant that people did not always have their needs assessed and care was not delivered in line with their care planning.

The premises were in need of some upgrading and general maintenance. However our main concern in this regard was that the environment was not configured in a way to benefit people living with dementia.

Following on from the July inspection we requested and received from the provider a plan of action to address the shortcomings we found. When we returned we found that substantial improvements had been made. There was still further work to be done, but we were satisfied that plans were in place to do this.

One person living in St Nicholas' told us, 'I can say if I do not agree with what staff say.' Another said, 'Staff have always got a smile and a laugh.' Relatives we spoke with told us they had seen improvements in the home, particularly around cleanliness and staffing levels.

People's dignity had not always been respected and some poor practices had been evident from our previous inspection. This inspection did not find that these instances had continued. Staff training in dignity was now being provided and open discussions had been held at a 'resident and relatives' meeting.

The provider had increased the hours dedicated to the cleaning of the home and after touring the building we were satisfied with the cleanliness of the premises.

Staffing levels had improved but there was still further work to be done.

We spoke with four people living at St Nicholas'. Three of them were satisfied with the care received. One person who felt poorly on the day of our inspection told us, 'Staff are always popping their head around the door to make sure I am okay.' Another person told us the care provided was 'all good, but there's never enough staff. But they are so kind, all of them.'

We were told of incidences where people were not supported to go to the bathroom and had been told this was because of insufficient staff. This did not respect people's dignity.

Care plans were in the process of being re-written. We found that care plans and risk assessments were now being reviewed regularly. Personalisation of care plans had begun but this work was still on-going.

We found considerable concerns regarding staffing levels and staff training. The service performance was not being monitored and had not been for some time.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

The central heating and hot water systems had failed eight days prior to our visit and the home was without central heating and hot running water. Portable heaters were in use and a hot water urn was in operation on each floor. Whilst the home was managing, some people we spoke with expressed disappointment that a problem had been evident for some time and it appeared to them that only now the systems had failed was anything being done to deal with the problem. The manager had been in post for two weeks and had industrial plumbing and heating engineers in to quote for the work required and had submitted several quotes for the consideration of the provider.

We reviewed some staff records and found that whilst Criminal Records Bureau (CRB) checks had been carried out, there were a few gaps in other areas, for example, staff files did not always contain up to date photographs.

We found that medicines were safely stored and administered.