St Annes Nursing Home

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

Ongoing improvement was needed to ensure that all staff received the provider’s mandatory training updates and support through regular supervision. Care records were not always completed accurately which made it difficult to evidence that care was carried out as planned. People had access to healthcare services and were supported appropriately to eat and drink. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and relatives told us there was a positive atmosphere at the service and they received good quality care. They told us that staff were caring and attentive to their needs. Staff had a good understanding of how people would like to be supported and treated them with dignity and respect.

The clinical lead oversaw the day to day running of the service. They had worked to make improvements to the service since they started and demonstrated an open and transparent approach during our inspection. They completed regular quality audits of the service and had a good understanding of the strengths and key challenges the service faced.

The environment was suitable to meet people’s needs. There were policies and processes in place to manage risks related to health and safety, infection control and risks related to people’s medical conditions. Staff had a good understanding of how to mitigate risks related to people’s care and there were good supplies of equipment in place to promote safe care. There were enough staff in place to meet people’s needs.

People’s care plans were reflective of their needs and preferences. Relatives told us they felt welcome by staff when visiting and felt consulted about their loved one’s care. People told us they felt happy to raise complaints or concerns to the provider and that issues were resolved. Staff had training and knowledge in providing empathetic and responsive end of life care.

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

Rating at last inspection

The last rating for this service was good (published 5 April 2019)

Why we inspected

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

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

¿ People living at St Anne’s Nursing home were aged over 65 and had nursing care needs. Some people were living with dementia.

¿ St Anne’s Nursing Home is registered to provide care for up to 58 people. At the time of inspection there were 38 people using the service.

¿ For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

People’s experience of using this service:

¿ People received safe care. The provider mitigated risks associated with people’s health and had systems in place to protect them against the risks of abuse and harm.

¿Staff received appropriate training and support in their role. The provider had effective systems in place to assess people’s needs and promote good outcomes for their health and wellbeing.

¿ Staff were caring and knowledgeable about people, treating them compassion and dignity.

¿ People received responsive care in line with their needs and preferences. This included when they received care at the end of their lives.

¿ 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.

¿ The registered manager was effective in their role and responsive to feedback. The provider had systems in place to monitor and improve the quality of care.

Rating at last inspection:

¿ At the last inspection the service was rated Requires Improvement (9 May 2018). The rating has improved since the last inspection.

Why we inspected:

¿ All services rated "Requires Improvement" are re-inspected within one year of our prior inspection.

¿ This inspection was part of our scheduled plan of visiting services to check the safety and quality

of care people received.

Follow up:

¿We did not identify any concerns at this inspection. We will therefore re-inspect this service within the published timeframe for services rated Good. We will continue to monitor the service through the information we receive.

We undertook this unannounced focused inspection on 22 February and 1 March 2018. The inspection was in response to a number of concerns which were raised with the Care Quality Commission and by the local authority safeguarding team. The team inspected the service against three of the five questions we ask about services: is the service safe, is the service effective and is the service well led?

St Annes Nursing Home is registered to provide accommodation and nursing care for up to 58 people. Many of the people using the service lived with dementia. On the first day of our inspection, there were 35 people living there.

There was a registered manager in place. 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.

St Annes 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.

Appropriate recruitment procedures were in place but not always followed by the registered manager. People received their medicines as prescribed but would benefit from staff having a deeper understanding of people’s needs regarding the use of the medicines. Consent to care was not always sought in line with legislation and guidance. Infection control procedures were in place and the home was clean, with the exception of one piece of equipment. The provider did not always ensure that notifiable incidents were reported to the CQC. The provider had a quality assurance system in place to audit and monitor the quality of the service, however, this did not identify the issues of concern we found during the inspection. New staff received induction training and there was a training programme in place. However, some staff had not received up to date training. Staff were not always supported in their work through the use of supervision.

Procedures were in place to protect people from abuse and staff had completed training in safeguarding people. Risk assessments identified when people were at risk from every day activities. People were supported by sufficient numbers of staff.

People’s needs were assessed and their preferences understood before they moved to the service. People were supported to eat and drink and most enjoyed their meals.

People had access to healthcare professionals when necessary. The building was purpose built to meet the nursing needs of people who lived there.

The registered manager demonstrated effective partnership working with other health and social care professionals. Lessons were learned and improvements made when incidents occurred in the home. The provider had sought the views of people living at St Annes Nursing Home.

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.

People said they would like more activities and relatives identified that people would benefit from additional mental and physical stimulation. We have made a recommendation about this.

There was an open and transparent culture within the home. The management team were approachable. People and visitors felt the home was run well. Staff understood their roles, were happy in their work and worked well as a team.

Quality assurance systems were in place using formal audits and regular contact by the registered manager and director with people, relatives and staff. Policies and procedures had been reviewed and were available for staff.

People felt safe and staff knew how to identify, prevent and report abuse. Legislation designed to protect people's legal rights was followed. Staff offered people choices and respected their decisions. People were supported and encouraged to be as independent as possible and their dignity was promoted.

Care plans provided comprehensive information about how people wished to be cared for and staff were aware of people's individual care needs and preferences. Reviews of care involving people were conducted regularly. People had access to healthcare services and were referred to doctors and specialists when needed. At the end of their life, people received appropriate care to have a comfortable, dignified and pain free death.

There were enough staff to meet people's needs. Staff worked well together, which created a relaxed and happy atmosphere that was reflected in people's care. The recruitment process helped ensure staff were suitable for their role. Staff received appropriate training and were supported in their work.

People and external health professionals were positive about the service people received. People were positive about meals and the support they received to ensure they had a nutritious diet. Procedures were in place to ensure medicines were managed safely. Individual and environmental risks were managed appropriately.

People and relatives were able to complain or raise issues on a formal and informal basis with the registered manager and were confident these would be resolved. This contributed to an open culture within the home. Visitors were welcomed and there were good working relationships with external professionals.

Plans were in place to deal with foreseeable emergencies and staff had received training to manage such situations safely.

There was a registered manager in place. 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 previous comprehensive inspections in January 2015, we identified that improvements were required to ensure people’s legal rights were protected and mental capacity legislation was complied with. We made a compliance action telling the provider they must make improvements. We received an action plan from the provider stating what they would do to meet the legal requirements in relation to improving their service. At this inspection we found improvements had been made.

Staff followed legislation designed to protect people’s rights and freedom to help make sure decisions were only taken in the best interests of people.

Although there where suitable arrangements were in place for managing medicines administered one nurse failed to fully follow safe administration procedures.

People felt safe at the home. Care staff knew how to prevent, identify and report abuse.

Safe recruitment procedures were in place although a full employment history had not been sought for two new staff. Staff were suitably trained and appropriately supported in their role.

People and relatives were positive about the service they received. They praised the staff and the care provided. People received personalised care from staff who understood their needs and they were supported to make choices although they had not acted to prevent a person inappropriately assisting another person with their meals. We observed occasions when staff failed to acknowledge people when they entered communal rooms. However at other times staff treated with respect.

Care plans provided comprehensive information about how people wished to be cared for and staff were aware of people’s individual care needs. Individual risks to people were managed effectively. At the end of their life people received appropriate care to have a comfortable, dignified and pain free death.

People had access to healthcare services and were referred to doctors and specialists when needed. Reviews of care involving people or relatives (where people lacked capacity) were conducted regularly. Staff recognised that people’s needs varied from day to day and responded effectively. The provider had identified a need to increase activities staff and was recruiting to this post.

Plans were in place to deal with foreseeable emergencies and staff had received training to manage such situations safely. There was an environment maintenance and improvement program in progress.

Staff treated people with kindness and compassion and formed caring relationships with them and their relatives. Staff protected people’s privacy, promoted their independence and involved them in planning the care and support they received. People were also positive about meals and the support they received to ensure they had a nutritious diet.

People liked living at the home and felt it was run well. There was a clear management structure in place. Staff understood their roles, were happy in their work and worked well as a team.

There was an open and transparent culture. The provider encouraged staff feedback and visitors were welcomed. Complaints, when received, were investigated and responded to. Quality assurance processes were in place to assess key aspects of the service. Where these had identified a need for improvement action had or was being taken.

At this inspection we found the provider was not meeting the requirements of the three regulations we assessed.

We spoke with 8 of the 32 people at the home. We also spoke with three relatives and six staff, the registered manager and the Nominated Individual. We observed care in communal areas and viewed records relating to care and the management of the home.

We considered three outcomes during this inspection. These being

Outcome 4 Care and welfare of people who use services

Outcome 16 Assessing and monitoring the quality of the service

Outcome 21 Records

We considered all the evidence we had gathered under the outcomes inspected. We used the information to answer four questions we always ask.

Is the service safe?

People told us they were happy with the service they received. We spoke with relatives and visitors who were also positive about the service and said they felt their relatives were safe. One person said 'I like it here, I am well looked after'.

However, we found people were not always receiving the nursing and personal care they required. Care was not always planned and delivered in an appropriate way to ensure the welfare and safety of people. Records could not confirm people had received all the care they required. Following the inspection we made a safeguarding referral because action had not been taken when people developed bruises of unknown origin. The home was not always ensuring people's legal rights were protected and mental capacity assessments and best interest decisions had not been held where necessary.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service had made a DoLS application to the Local Authority on behalf of one person.

Is the service effective?

We could not be assured that people were receiving effective care. A person said they 'were satisfied with the care they received, however, the staff were very busy and did not have time to chat'. People had individual care plans. However, these lacked individual detail as to how people's needs should be met. Care plans contained conflicting information about people's needs and reviews had failed to identify this. Records viewed could not confirm people had received all nursing and personal care they required. The service was therefore not always effectively meeting their nursing care needs.

Is the service caring?

People made positive comments about the service they received. A person told us 'No complaints [the staff] are very caring and look after me very well'. Visiting relatives were also happy with the way their loved ones were cared for. One relative said 'the staff are fantastic', they went on to add that they felt there needed to be 'more mental stimulation and activities'.

Staff said they usually had time to meet people's identified needs and could provide care at the times people wanted it. We observed staff interacting in a warm and friendly way with people. Care and support provided by care staff seemed to be kind and friendly but contact was brief and focused on routine events such as lunchtime when people were wheeled into the dining area and ate their meals whilst sat in their wheelchairs. People were at risk of injury and one had suffered bruising which a record log attributed to non-compliance with personal care. People had therefore not always received a caring service.

Is the service well-led?

The provider and registered manager have failed to adequately address the concerns identified following the previous inspection in March and April 2014.

A range of audits and procedures to monitor the quality of the service had been carried out. However, these had not identified or set in place actions to rectify the continuing concerns with the service provision and record keeping.

We considered all the evidence we had gathered under the outcomes inspected. We used the information to answer the five questions we always ask.

Is the service safe?

We found serious failings in relation to the assessment, planning and delivery of care for people at the service. We found people had been placed at risk as they had been given inappropriate food or drink. Records of care could not confirm that people had received the care and support necessary to ensure their safety. In our previous two inspections we found the procedures and systems in place for the management of medication were inadequate to ensure people's safety. At this inspection we found necessary steps had not been taken to address all concerns. Ongoing issues regarding the management of medicines meant people's safety and welfare were still being put at risk.

People were protected against the risk of infection because the provider had addressed issues identified at our previous visit and taken necessary steps to ensure care was provided in a clean, hygienic environment.

Is the service effective?

We found there were insufficient qualified nursing staff employed which meant the registered manager was undertaking many nursing shifts. This meant they were unable to spend sufficient time on their management role and responsibilities.

Care staff did not always have all the information they required to meet people's needs.

Is the service caring?

People were supported by kind and attentive staff and we saw people were treated with respect and dignity by staff. We saw care workers were patient and listened to people's requests and views. However, people told us they thought the service did not have enough staff and they had to wait for call bells to be answered.

Is the service responsive?

Failure to properly assess people's needs and plan their care to meet those needs meant people were not protected against the risks of receiving inappropriate or unsafe care. We also found that systems were not in place to ensure people received nursing care such as wound care and a GP's treatment plan had not been followed.

Systems to reduce the risks of reoccurrence following accidents or incidents were ineffective as the registered manager was not made aware of all accidents and incidents.

Is the service well-led?

There were inadequate quality assurance procedures to ensure the quality of the service provided. People's views were not regularly sought and there were no systems to formally monitor the quality of care people received, care planning or record keeping.

People's personal records including medical records were not accurate, complete or fit for purpose.

We spoke with thirteen people living at the service, a relative, the provider, registered manager and twelve members of staff. People told us the 'staff are lovely,' and they 'couldn't be nicer.' Another person told us 'whenever I ask for help, they [staff] help me with everything I need.'

We observed staff supporting people with day-to-day activities. The interaction was observed to be sincere, respectful and responsive to individual support needs. However, we identified failures with key systems and processes for the assessment, planning and provision of care and support. This meant the provider was unable to demonstrate they were meeting everybody's care and welfare needs effectively. Emergency call bells were not available to all people at night-time, which meant people's safety and welfare were not being maintained at all times.

People were protected from the risk of infection because the provider had taken steps to ensure care was provided in a clean, hygienic environment. People received food and fluids appropriate to their needs. Where necessary, people received support to ensure they received adequate nutrition.

Our previous inspection found the procedures and systems in place for the management of medication were ineffective. At this inspection we found necessary steps had not been taken to address those issues. The systems for the management of medication remained ineffective, which put people's safety and welfare at risk.

There were enough qualified, skilled and experienced staff to meet people's needs. However, lack of qualified nurses meant the manager sometimes had to provide essential nursing cover.

People's personal records including medical records were not accurate, complete or fit for purpose. Errors and omissions identified in plans and records of care meant the service's records systems were not adequate for supporting the effective planning and delivery of care and treatment.

We observed people's choices and consent to care and support were respected at all times during our visit. We observed staff supporting people with day-to-day activities. The interaction was observed to be sincere, respectful and responsive to individual support needs.

In our previous inspection we found there were issues with care plans and judged the provider to be non-compliant in this area. We reviewed care plans at this inspection, and found improvements made meant they were now sufficient to ensure and demonstrate people's care and welfare needs were being met.

The procedures and systems in place for the management of medication were ineffective.

In our previous inspection we found there were issues with support for staff and judged the provider to be non-compliant in this area. We reviewed support for staff at this inspection and found the provider had taken additional steps to ensure sufficient support for staff. Staff received training and development opportunities to enable them to carry out their work effectively.

There were systems in place to regularly assess and monitor the quality of service that people receive.

People expressed their views and were involved in making decisions about their care and treatment. Privacy, dignity and independence were respected and people were treated as individuals.

We reviewed care plans, and found ongoing issues with completeness and lack of personal information. Plans did not ensure or demonstrate everybody's care and welfare needs were being met. However, staff were knowledgeable about people in the home, and support was observed to respectful and responsive to individual needs.

We found there were effective procedures and systems in place for cleanliness and infection control. People were protected from the risks of inadequate nutrition and dehydration.

The provider had made some improvements in its support for staff. However, we found there were still issues with support and supervision and some staff did not feel fully supported. The provider had improved its systems for assessing and monitoring the quality of service people received. However, they were unable to demonstrate how they had responded or planned to respond to results of their own audits and assessment.

People told us that they enjoyed the meals provided at St Anne's Nursing Home. However, there was no choice of menu for people at lunch time and we observed that people were not given a choice of where to take their lunch.

Procedures to promote infection control were not adequate. There was soap and towels missing from bathrooms and bathrooms, this meant there were no facilities for staff or people who used the service to wash their hands in these rooms. There was no evidence that the effectiveness of infection control practice at the home was monitored.

The provider was unable to demonstrate that relevant and appropriate training and support was provided to staff who worked at the home. This meant that it could not be assured that people received care and support from staff who were suitably trained and skilled.

The provider was unable to demonstrate that the views of people who lived at St Anne's Nursing Home were taken into consideration in the development of the service.