Archived: St Andrew's Care Home

The bedrooms in the main house are over two floors and reached by a passenger lift. There are four bedrooms in an annexe; three of which are reached by a stair lift. The annexe is accessed across a courtyard away from the main building.

This unannounced comprehensive inspection took place on 15, 22 and 27 November 2017. It was carried brought forward due to the service being part of a whole home safeguarding process.

When we inspected, the service did not have a registered manager, they had voluntarily cancelled their registration with the Care Quality Commission (CQC) from August 2017. A registered manager is a person who has registered with the 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. A new manager had been appointed on 24 July 2017. At the time of the inspection, they had applied to register as a manager with CQC.

The service was not well led. The service lacked effective leadership and the management style was often reactive rather than proactive. There was not an effective system to regularly monitor and assess the quality of the service and the risks to the people living there. The provider had not demonstrated good practice in the way they had recruited new staff and assessed people new to the service. They had not considered the impact on staff or people living in the home when they admitted a person as an emergency. The provider had not considered the outcome of not funding agency staff during day shifts which had impacted on staffing levels and resulted in two staff working long periods of time.

The provider had not kept people living at the home and relatives or visitors informed of the changes of management. They had imposed charges for equipment without an explanation to relatives or the person involved; they had not overseen how people’s personal allowances were managed. This meant there was no audit trail to record transactions and people’s relatives had been presented with bills backdated to 2015. They did not make records of their audits available at the service to show how they had judged the environment and people were safe and well cared for.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions, and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection, there was not a consistent approach to making applications to the local authority in relation to some people who lived at the service. People were not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible; the systems in the service do not support this practice. People were not routinely involved in their care plans or reviews so their consent was not gained. Best interest decisions were not recorded and documentation linked to lasting power of attorney was not requested. These practices meant people’s legal rights were not protected.

Recruitment practice did not ensure all the necessary information was in place before staff started working at the home. We saw examples of kind care, with staff showing affection and compassion towards people. However, there were also practices which undermined people’s dignity and privacy. Staff were attentive and positive about their role but some people commented that they could feel rushed by some staff who did not take to time to ensure they understood them.

Safety checks were carried out but the systems in place were not thorough and potentially left people at risk of harm. Laundry arrangements and a lack of guidance around infection control posed potential risks to staff and people’s health. A few items of furniture were damaged and the odour in one room had not been addressed in an effective way. Work had taken place to re-decorate areas of the home and the furniture in the dining room had been updated, which people commented positively on.

People were supported to see, when needed, health care professionals. Care staff recognised changes to people’s physical well-being and visitors said they were kept informed by staff regarding their relative’s health and well-being. The administration and storage of medicines was well managed, apart from for one person, where their prescribed creams were inappropriately stored. People were supported with their meals, where needed, and people’s weight and fluid intake was monitored.

During our inspection, we found a number of areas that needed to improve to maintain the safety and well-being of people that had not been identified by the registered manager or the providers. We found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have made recommendations linked to the design of the environment, making complaints information accessible and end of life care. You can see what action we have told the provider to take at the back of the full version of this report.

We are taking further action against this provider and will report on this when it is completed. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

During the inspection, we contacted the local authority safeguarding team, commissioners, deprivation of liberties team and community nursing team so they were aware of the potential risks to people’s safety and well-being at the home.

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.

We visited St Andrew’s Care Home on 1 and 2 November 2016 when we judged their overall rating was ‘Good.’ However, some aspects of recruitment practice needed to be improved to ensure only staff suitable to work with vulnerable people were recruited which was a breach of regulations. We received an action plan following the inspection, which demonstrated the steps taken to improve recruitment practice. We returned to the home on 26 April 2017 and re-inspected the question is the service safe? We judged improvements had been made in the way staff were recruited and the breach had been met.

On 9 June 2017, we received concerns about some aspects of the service. We shared these concerns with the local authority safeguarding team and commissioners. They immediately arranged for health professionals to visit the home on a daily basis to monitor people’s well-being and safety. We attended a whole home safeguarding strategy meeting on 15 June 2017 and heard feedback from health professionals. The provider and registered manager were also invited to attend part of the meeting to hear the concerns and give their response. We then carried out an unannounced inspection on 16 June 2017 and fed back our findings to the registered manager and provider. As we had re-inspected all aspects of the question relating to safe on 29 April 2017 and found people were kept safe, we focused on the concerns that had been raised about the service. Following a safeguarding investigation, we completed a second day of inspection on 7 July 2017. Since the inspection, the provider has kept CQC updated on the steps they have taken to address the areas identified for improvement.

These concerns related to how one person was moved, unprofessional practice by staff towards each other and in the way they spoke with people and people being socially isolated. Health professionals also raised concerns about a piece of equipment that did not work, poor moving and handling practice, poor standard of cleanliness in some rooms, lack of accessibility of drinks, the conduct of a staff member and the use of personal mobile phones to store people’s care records.

There was a registered manager at the service who had registered with CQC. 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 some carpets and furnishings were unclean, broken and smelt unpleasant; the provider took immediate action to address this. The stair lift was unreliable, which impacted on people accessing other areas of the home; a system was put in place to ensure staff used the equipment appropriately to ensure it remained charged for the next person to use. Before the inspection, the registered manager had ensured care records were deleted from staff members’ mobile phones; tablets were available for them to access people’s care records.

Staff were up to date on the current needs of people living at the home to help keep them safe but some care records had not always been updated with this information, which had been addressed by the second day of our inspection. We saw staff were responsive to people’s changing needs to help keep them safe. Care staff worked well as a team and were caring in their approach. They made sure drinks were available to people.

Staff supported people in a safe and consistent way but the amount of hours worked by some staff had not been effectively monitored, which could potentially lead to unsafe practice. The provider told us how this was being addressed and monitored. Unprofessional behaviour by staff towards each other had not been effectively addressed; the provider has updated us on the disciplinary action now being taken.

CQC have requested monthly reports from the provider of the actions taken following their quality assurance checks. These will be reviewed and if necessary a comprehensive inspection will be brought forward to judge if the service is well run.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Andrews Care Home on our website at www.cqc.org.uk. At this inspection, we found that the service had improved and now met the relevant legal requirements.

St Andrew’s Care Home is registered to provide accommodation for 23 people who require personal care, some of whom are living with dementia. At the time of the inspection there were 20 people living at the service. There was 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 living at the service said they felt safe and appeared relaxed and happy.

All staff had received training in how to protect people from avoidable harm and abuse and knew what to do in the event of a concern. This training was regularly updated and monitored by the registered manager.

Risks to people were assessed and action taken to ensure they were kept to the minimum level so that people’s freedom was respected and not restricted. Suitable measures were in place to mitigate the risk of pressure sore damage, such as use of specialist mattresses. Equipment was serviced regularly; premises were risk assessed with audits undertaken at suitable intervals. Personal emergency and evacuation plans (PEEPS) were in place for everyone living at the service.

Recruitment procedures had been improved and now ensured that suitably qualified and experienced staff were appointed in order to keep people safe. There were sufficient numbers of staff on duty. Staffing levels had been increased recently and were reviewed regularly in response to people’s needs, with adjustments made. The registered manager monitored staff working hours to ensure they were kept at a reasonable level so as not to compromise safety. Call bells were answered promptly.

Medicines were audited on a weekly basis with errors investigated and learning disseminated.The storage and administration of medicines was carried out safely.

We last visited St Andrew’s Care Home on 21 and 24 September 2015 when we judged their overall rating was ‘Requires Improvement’ as there were areas that needed to be improved. We received an action plan following the inspection, which demonstrated the steps taken to address concerns.

There was a registered manager at the service who had registered with CQC. 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.

Staff practice respected people’s choices and valued people as individuals so staff knew when to change their approach based on their knowledge of the person. There were positive relationships between staff and people living at the home. People told us they felt safe. There were systems in place to protect people from harm and abuse. Medicine practice had improved and was well managed.

People were supported to make decisions about their care and support and

staff obtained their consent before support was delivered. Care plans helped promote a person centred approach to help staff respect people’s histories, wishes and social needs. People were encouraged to suggest ideas for activities and staff recognised people’s differing needs and personalities in the way activities were provided.

Improvements were taking place to make the garden more accessible and some areas of the home had been refurbished and updated. The carpets in two people’s rooms needed replacing. The registered manager said they had encouraged the people using the rooms to allow this to happen but records were not kept of these discussions. Following the inspection, the registered manager put in a new system to record discussions around the environment.

Some aspects of recruitment practice needed to be improved to ensure only staff suitable to work with vulnerable people were recruited. There were sufficient numbers of suitable staff available to meet people's individual needs. Staff knew their responsibilities to safeguard vulnerable people and to report abuse. Staff received support to develop their skills and ensure they were competent in their work.

People were kept informed about changes within the home and plans to improve the service through meetings and newsletters. The registered manager was known to people living at the home. Improvements had been made to the complaints system. This meant there was clearer information and a commitment to respond in a timely manner.

Staff were aware of their responsibilities in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and demonstrated through their practice an understanding of how this impacted in the way they worked. People were offered a choice of meals. Staff were responsive if people were unhappy with their choice and quickly provided an alternative. People were supported with their health needs and had access to health and social care professionals, when necessary.

The registered manager had worked hard to build up staff morale as she recognised a happier staff team created a positive atmosphere for people living at the home. She had established a service where staff were clear about the values and ethos of the home. There were systems to monitor the quality of the service, including responding to suggestions for improvements. You can see what action we told the provider to take at the back of the full version of the report.

Is the service safe?

People told us they felt safe with staff. The service was safe because care records were up to date and reflected people's current health and emotional care needs. The manager ensured equipment and the premises were well maintained and safe. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, the manager understood when an application should be made, and how to submit one.

Is the service effective?

People living at the home told us they were happy with the care at the home. The service was effective because people's health and care needs were assessed and care was provided which met their assessed needs. People said they felt listened to by staff; although some people told us there was not enough to do. Quality assurance systems in the home were effective and the manager acted upon their results to improve the service.

Is the service caring?

People told us they were supported by caring staff, which was confirmed by a relative. Our conversations with the manager and staff demonstrated they were committed to provide good quality care. We also saw positive written feedback from relatives who visited the home.

Is the service responsive?

The service was responsive because the manager had contacted health and social professionals appropriately when people's care needs changed. People told us they were well cared for and health professionals were contacted in a timely manner.

Is the service well-led?

The service was well led because the manager monitored the standard of care and the standard of the environment on a regular basis. People living at the home and staff told us the manager was approachable and they could share their views and ideas for improvement, which was confirmed by completed surveys.

In this report the name of a registered manager appears. However, at the time of the inspection they were not managing the regulatory activity at this location. Their name appears in the report because they were still a registered manager on our register at the time of the inspection.

This inspection was carried out to follow up the provider's action plan following non-compliance identified during an inspection undertaken by us in September 2013. The provider's action plan stated the majority of the actions would be completed by 28 February 2014. We also looked at how medicines were managed as this had been identified as non-compliant in December 2013 during a responsive inspection following concerns raised by safeguarding nurses. Information we received from the manager stated they felt medicines were now managed appropriately. We saw the provider and manager had worked hard to raise standards within the service.

There were fifteen people using the service at the time of our inspection. The people we met during our inspection spoke positively about the service. Comments included; 'I'm comfortable here, I like the home; it's alright'. 'I'm happy that the staff look after me so well'. And, 'The home is very much improved recently. The atmosphere is much better and we don't feel we're in the way anymore'. Visiting professionals also told us they had seen improvements in recent weeks; however they recognised further improvements were required in some areas of the service.

We saw improvements in the way people were cared for; falls and pressure sores had reduced and people were more involved in the day to day running of the service. However the improvements had not yet resulted in a service which was safe, responsive and effective for the most vulnerable people using the service.

We saw improvements in the way medicines were stored and managed. The way the premises were maintained and facilities within the service had been improved; these provided better comfort for people using the service. There was enough equipment to promote the independence and comfort of people who used the service. These improvements reflected the efforts made by the provider and the staff team in raising standards in the service.

There were not enough qualified, skilled and experienced staff to meet people's needs. This was particularly noticed for the night time and weekend periods and may have contributed to a person acquiring a 'grade 3' pressure sore. However staff support had improved with training in a number of areas having been provided alongside more regular staff meetings and recent appraisals.

We saw improvements in audit and quality assurance processes, however there was still room for improvement. Audits were not sufficiently detailed and missed indicators which meant the provider did not have a robust process for the management of risk.

We looked at the records of seven people using the service and found that some people's personal records including health care records were not accurate and fit for purpose. We saw improvements in the way the majority of care files were now organised and in the information which had been provided about people; however the care plans lacked detail which could impact on the care and support provided.

We found that people were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. Our inspection found there was a lack of leadership and guidance which meant staff who administered medication had not routinely had their medication training updated or their administration audited. However the provider had recognised this lack of support and had arranged for further training. A consultant had been employed by the provider and improvements in medication recording were observed.

The people living in the home spoke positively about the service and the staff who worked there. One person told us, 'The staff are lovely, so helpful and kind'. People told us they were treated with respect and kindness and told us staff respected their privacy. A visitor we spoke with told us, 'I'd be devastated if mum couldn't stay here'; whilst another visitor told us, 'They are very caring here, I'm very happy with my mother's care'.

Whilst staff had a good awareness of individual people's needs, preferences and choices some aspects of the way they supported people required improvement. We saw improvements in the way hygiene and infection control was managed within the home. The home appeared clean and tidy and odour free. Where we highlighted concerns to the manager we saw that they responded positively and put measures in place to improve services to people living in the home.

Other aspects of the service did not meet the standards expected under the current regulations. We saw that staff development and support was inadequate resulting in poor moving and handling of people using the service. Also, instructions about the day to day operation of the home were not being followed. Care file records and care plans about the people the staff supported were not up to date and had sections that were incomplete or blank. Quality assurance processes whilst improved in some areas required further improvement in other areas to ensure people were supported safely.

Facilities on the premises were not sufficient or accessible enough to safely meet the needs of all the people using the service. Storage space for equipment was inadequate and there was insufficient equipment to ensure safe administration of medication. The manager told us the provider was considering improvements in these areas; however these were concerns which we had identified during our last inspection.

There were 21 people living in the home at the time of our inspection. People were able to move freely about the home and outside and were comfortable in each others company as well as with the staff who supported them. One person told us "I get a good quality of service here" whilst another said "I really enjoy the care provided here."

We looked at the care records of six people living in the home and the records of four staff on duty on day one of our inspection. We talked with nine people who lived in the home, six staff from the home, the manager, a visiting professional and three visitors. The professional told us "Staff here are good at keeping in touch about people's health needs." Visitors we spoke with told us staff were, 'Very good, they are as good as gold, a good crowd.'

People were treated with respect and were involved in their care, their care and welfare was generally well supported and they were safeguarded from abuse. Some aspects of hygiene and infection control and quality assurance require improvements and some aspects of staffing require consideration.