St George's Care Homes

St Georges is a 'care home' providing accommodation, nursing and personal care for up to 50 older people; some of whom lived with dementia. At the time of the inspection 37 people were living at the home.

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

The registered manager was clear about how the service should be provided and they led by example.

The provider had systems in place to protect people from the risk of abuse and people told us they felt safe. Risk assessments were completed to help identify and minimise risks people faced.

Infection control measures were safe. Steps were taken to learn lessons if things went wrong.

Staff were caring and treated people with kindness and respect. There was enough staff on duty to meet people's needs. Incidents and accidents were managed safely, the managers took necessary actions to keep people safe and minimise the risk of incidents reoccurring.

We received positive feedback on the service. One person said, “The care seems very good and they seem well staffed” and another said, “With the new manager it’s really good.”

Care and treatment was planned and delivered in a way that ensured people's safety and welfare. People were cared for and supported by staff who had received appropriate training. There were systems in place to minimise the risk of infections. There were safe medicine procedures for staff to follow.

The registered manager provided good leadership and clear direction. Staff felt supported and were confident people received good care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way and in their best interests; the policies and systems in the service supported this practice.

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

The last rating for this service was requires improvement (published 21 December 2021).

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

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

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

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

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

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

Follow up

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

St Georges is a 'care home' providing accommodation, nursing and personal care for up to 60 older people; some of whom lived with dementia. At the time of the inspection 35 people were living at the home.

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

People were not fully protected from the spread of infection. COVID-19 testing taking place at the home was not always carried out in line with government guidance. These matters were addressed at the inspection. Risks were not always fully assessed, monitored and reviewed. Risks such as falls and malnutrition were not always monitored and recorded appropriately. Some key information in people’s care records about the management of risk were not accurate with daily notes missing key information.

People told us they were pleased with the care they received and said they felt safe living at the home. One person said, "This is the best placed I have been in terms of care homes. Everyone is attentive and looks after me well." People living at the home were relaxed and happy with staff. Staff spent time chatting with people and supporting them when they became distressed.

People were protected from abuse because staff understood what was meant by abuse and the correct procedures to follow if they had any concerns about people’s safety. People received their medicines as prescribed and staff had clear information about how people liked to be supported with their medicines. Staff were knowledgeable about people's health needs and the provider had sought support from other health professionals as appropriate to support people's needs.

Staffing levels were appropriate and matched the dependency tool being used to match the needs of people at the home. A high volume of agency staff were used. The provider assured us they were continuously working to recruit more permanent staff. Staff received training and support to enable them to effectively meet the needs of the people they supported.

Rating at last inspection

The last rating for this service was good (published 20 October 2020).

Why we inspected

We carried out an unannounced focused inspection of this service on 25 November 2021 following a number of concerns relating to staffing numbers and intelligence gathered through various sources and our system. This report only covers our findings in relation to the key questions of safe and well-led.

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.

Our report is only based on the findings in those areas at this inspection. The ratings from the previous comprehensive inspection for the caring, effective and responsive key questions were not looked at during this visit. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used to calculate the overall rating at this inspection.

The overall rating for the service has deteriorated to 'requires improvement'. This is based on the findings at this inspection. We found evidence that the provider still needs to make improvements.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St George Care Homes on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection we have identified breaches in relation to safe care. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St George’s Care Homes is a residential care home providing personal care and nursing care for up to 60 people aged 65 and over. There were 26 people living at the home at the time of this inspection.

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

People said there were enough staff available to help them when needed. Comments included, “The staff come quickly when I need them” and “Staff come quick, press my bell and they are there, always enough staff.” Staff were available to promptly assist people throughout our inspection and staffing levels were regularly monitored, reviewed and amended when needed by the registered manager.

People told us the home was a safe place to live. One person commented, “I feel safe with the staff, I trust them. I know all the staff pretty much, it makes me feel safe.” Staff had received safeguarding training and understood their role in recognising and reporting safeguarding concerns.

We observed a helpful, caring and attentive culture amongst staff at the home. Staff were familiar with the people they were supporting and had a good rapport with them.

Relatives said they had good communication with staff at the home and staff helped them to keep in touch with their loved ones whilst COVID-19 visiting restrictions have been in place. One relative commented, “We've developed a positive relationship with the staff. We have regular and honest communication with the staff and trust they'll contact us about [relative] if needed.”

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

Rating at last inspection

The last rating for this service was good (published 4 March 2020).

Why we inspected

This focused inspection included the key questions of safe and well-led and was prompted in part due to concerns received about staffing levels at the home. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.

We also 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 coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St Georges’ Care Home is a care home providing personal and nursing care and is registered to provide care to 60 people. There were 34 people receiving at the time of this inspection.

People felt safe using the service and were protected from abuse and the risk of abuse. Procedures were in place for the safe management of medicines and people received them on time. Safe recruitment practices were followed. Infection control practices were followed to minimise the risk of the spread of infection and regular safety checks were carried out on the environment and equipment.

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's needs, and choices were assessed prior to moving into the service. People received care and support from experienced staff who received training and were supported for their roles. People were supported to have a nutritious and balanced diet and their healthcare needs were met.

People and their family members felt the service met their needs and positive relationships had been formed with the staff delivering care and support.

People and their family members had access to information about how to make a complaint about the service.

Systems were in place to monitor the quality of the service that people received. The registered manager sought information and guidance from other agencies to continually develop the service.

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

Rating at last inspection

The inspection was prompted in part due to concerns received about staffing levels. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.

Following the last inspection, asked the provider to complete an action plan to show what they would do and by when to improve the key questions, is the service safe, effective, responsive and well led, to at least good. We found that the home had addressed these problems and that the service had improved to good.

St George's Care Homes (St George’s) 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.

The building was converted from a community hospital which had been built about 50 years ago. It was over two floors and had single and double rooms. A lift connected the floors. The home was in a residential part of Liscard in Wallasey and shops and community facilities were nearby.

The home is registered to provide accommodation, nursing and personal care to up to 60 people. At the time of our inspection, there were 21 people in the home.

The home requires 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. There was a registered manager in post who had been there for most of 2018 but whose registration had become final in December 2018.

The provider had also commissioned a specialist service to support and maintain the improvement required in the home.

We found that the home was a safe environment for people, who were supported by properly recruited staff who administered their medication correctly and who followed the policies and procedures of the provider. There were appropriate staffing levels and people were treated without discrimination and their human rights were protected and promoted. Staff knew how to safeguard people from abuse and how to report any concerns about this or any other accident or incident.

The building had been purpose-built and it was safe and well maintained.

Staff were well-trained and supervised and had the skills and knowledge to deliver effective support to people living in the home. Staff understood the Mental Capacity Act 2005 and worked with other agencies to ensure that people had the right support. People were enabled 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.

Staff treated everybody with kindness and compassion and involved them in decision-making about their day-to-day lives. They promoted people’s equality and diversity, gave explanations and information in a way that people could understand and supported people’s well-being and right to privacy.

We saw that all the staff treated people as individuals. The records we saw demonstrated that each care plan was individual to the person it was about. However, whilst the care plans were person centred, the daily records lacked detail as they just gave bland statements. People and their relatives told us they were involved in any reviews about their family member’s care plans.

The people who lived in St George’s could join in with various activities throughout each day.

We saw that worked well with other health and social care professionals to provide support to each individual person who lived in St George’s.

The service completed various quality checks and audits including questionnaires to people using it, their relative’s and health and social care professionals.

Further information is in the detailed findings below.

St George’s Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

The home provides accommodation for people who require nursing or personal care. The home can accommodate up to 60 people. At the time of our inspection there were 21 people living in the home.

There was no registered manager in post at the time of our inspection. However, a new manager had been recruited and had started working at the home shortly after our last inspection in February 2018. 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 carried out a comprehensive inspection of the home in January 2018. The home was rated inadequate because we found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our last inspection in February 2018 we carried out a focused inspection assessing the home’s performance in the domains of safe and well-led. We found that the home remained inadequate in these domains and the overall rating for the home remained inadequate.

During these previous inspections we identified breaches of Regulations 9 (person-centred care), 10 (dignity and respect), 11 (consent), 12 (safe care and treatment), 13 (safeguarding of vulnerable adults), 14 (meeting nutrition and hydration needs), 17 (good governance), 18 (safe staffing levels) and 19 (safe recruitment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection we found that the home had made improvements and was no longer in breach of Regulations 9, 10, 13, 14, 18 and 19. The home had made sufficient improvements since our last inspection which meant the home was no longer in special measures. However, the home remained in breach of Regulations 11, 12, 17 and 20A (display of ratings).

We saw that fire safety and firefighting equipment at the home had been regularly checked and maintained. Staff had received fire safety training, several of whom had received additional training to help take responsibility for making people safe in the event of a fire. However, during our observations of the home we found some potential environmental fire risks. We also found that the information detailed in people’s personal emergency evacuation plans (PEEPs) was not fit for purpose and out of date. We noted that the local Fire Service visited the home shortly after our inspection and confirmed that these issues had been addressed and people would be safe in the event of a fire.

We found that some parts of the home were unclean and in need of repair.

We found that the home did not always act in line with the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). The home did not always appropriately obtain people’s consent to their care and it had not acted in line with the MCA when people lacked capacity to consent.

Staff were not always sure where to find the most up-to-date information they needed to safely and effectively meet people’s needs.

People’s personal information was not always kept securely.

The home had failed meet its legal obligation to display its most recent CQC inspection report and rating.

We noted that in a relatively short period of time the new manager, with the support of consultants and some oversight from the registered provider, had made many improvements to the safety and quality of care being provided at the home. However, as we have explained in this report, the home still requires improvement and remains in breach of the Regulations in some areas. These additional improvements must be delivered and sustained before we can consider the service to be well-led.

Medication was safely stored, administered and recorded. This had significantly improved since our last inspection.

During our last inspection we were concerned about how the home was managing safeguarding concerns, as the records we saw were incomplete and there was a lack of evidence to show that appropriate action had been taken. We were reassured to find that since our last inspection these safeguarding concerns had been appropriately investigated and resolved. Overall, this is an area in which the home has made significant improvements.

We reviewed the home’s supervision and appraisal records and found that staff had been supported with regular supervision meetings, at least every three months and in some cases more often. We also found that only eight of 46 staff had taken part in an annual performance appraisal. This was a poor level of completion. However, we noted that this was mitigated by certain factors, such as the manager had only been at the service for six months and during this time there have been more significant overall concerns about the performance and safety of the home which have taken priority.

We reviewed staff training records at the home and found 92% of staff were up-to-date with their required training. This included training in areas such as safeguarding vulnerable adults, dementia care, mental capacity, fire safety, first aid and infection control.

We reviewed four staff files, each of whom had started working at the home since our last inspection. We found that staff were safely recruited. Criminal records checks, known as Disclosure and Barring Service (DBS) records, were carried out. We also saw that official identification, such as a passport or driving licence, and verified references from most recent employers were also kept in staff files. We saw that new staff were supported with a 12-week induction process.

The home provides accommodation for people who require nursing or personal care. The home can accommodate up to 60 people. At the time of our inspection, there were 32 people living in the home.

There was no registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in January 2018, the home was rated inadequate. This was because the provider had breached multiple health and social care regulations which placed people at significant risk of harm. We undertook this visit because we had received information that people continued to be placed at significant risk because the service remained unsafe and poorly led. This type of inspection is called a focused inspection and this report will only cover our findings in relation to the domains of safe and well-led.

At our last inspection people’s needs and risks had not been properly assessed and managed. Information in relation to people’s care was confusing, contradictory and difficult to follow. At this inspection additional information had been added to people’s care plans but the information about their needs and risks was still insufficient and contradictory. People’s information was stored in two, sometimes three different places and records did not always correspond with each other or match professional advice given in respect of people’s care. This placed people at risk of unsafe and inappropriate support.

For example, one person’s care records indicated that they had pressure sores on their body. There was no adequate wound care assessment in place or clear information about the clinical care they required in respect of these wounds. Wound management is a basic aspect of good nursing care.

Nutritional information about people’s special dietary requirements was unclear. Some people’s records identified that they needed a specific diet to maintain their well-being or to prevent them from choking. Catering staff did not always have accurate information about these needs to ensure people received the diet they needed. This placed people at risk of harm.

The management of medication continued to be unsafe. One person’s records indicated that on an almost daily basis they had received too much of their medication and that the required time period between doses had not always been adhered to. Records relating to prescribed creams and other topical medications were inconsistent and did not show that people received the medicines they needed to maintain their skin integrity.

At the last inspection, accidents and incidents were occurring frequently and had not been appropriately reported. At this inspection, accidents and incidents were not being properly recorded or audited by the provider and it was difficult to ascertain the true number of accident and incidents that had occurred since the last inspection. This lack of adequate monitoring placed people at risk of continued accidents and incidents of the same nature.

We did not hear call bells ringing for long periods of time during our visit which would suggest that people’s needs were being met by sufficient staff. We observed however that at times a visible staff presence was sparse and some people who needed one to one support did not have this support at all times. We also found that there were gaps in people’s care records which indicated they did not always receive the care they needed. A staff member told us that there were not enough staff on duty to be able to complete all of the tasks required of them each shift. At the last inspection the number of staff on duty was insufficient and the provider had no effective method of determining what safe staffing levels should be. At this inspection, we saw that the number of staff on duty had been determined by the using a dependency tool designed to calculate safe staffing levels. We found however that the tool was meaningless as there was insufficient detail as to how staffing levels had been worked out.

At the last inspection a significant number of safeguarding incidents had not been appropriately identified, investigated and reported. At this inspection we found no improvements had been made. Safeguarding records were extremely poor and did not match what had been reported to the Local Authority or CQC. In addition, a number of safeguarding incidents had been logged by the provider but there were no records for the majority of these incidents to show that they had been investigated or responded to in a robust way. We found that the provider continued to fail in their duty to protect vulnerable people from potential abuse.

Records showed staff were not always recruited or managed in a robust way. One staff member had been recruited recently to work at the home, but their previous employment background was unclear and appropriate references had not been sought. We also saw that appropriate disciplinary and safeguarding procedures had not been followed in relation to another member of staff. This meant the provider did not have robust procedures in place to ensure that the staff employed were safe, suitable and fit to work with vulnerable people.

The service was not well-led. The provider’s audits and oversight of the service continued to be inadequate. The audits in place failed to identify continued concerns with risk assessment and care management, medication, safeguarding, accidents and incidents, staff recruitment and management and staffing levels. In discussions with the provider they failed to show that they were accountable for the service or that they had the knowledge and the competency to ensure the service was safe and well-led. During discussions we found that the provider failed to recognise the gravity of our concerns or the serious impact this could have on people’s health, safety and welfare.

The overall rating for this provider remains ‘Inadequate’. This means it will remain in ‘Special measures’ by CQC and will be closely monitored by CQC in accordance with our enforcement powers.

The purpose of special measures is to:

- Ensure that providers found to be providing inadequate care significantly improve.

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

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

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

St George’s Care 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. The home can accommodate up to 60 people. At the time of the inspection there were 36 people living in the home.

The home requires a registered manager. The previous registered manager had left the home in the period after the last inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The home was being managed by two deputy managers and a care consultant who had only been in post for a limited time prior to the inspection. The staff trying to manage the home did not have the time or the resources necessary to make sustainable improvements to the service and staff did not have confidence in the provider’s ability to make improvements.

All of the concerns identified at the previous inspection remained. We found that medication was still not safely administered. Risk assessments were poor and did not safely identify or help to manage risk. Safeguarding concerns was still not being dealt with safely or appropriately and people who lived in the home were at risk from harm or abuse.

Staff were not adequately inducted, trained or supported to do their jobs safely. The Mental Capacity Act was not lawfully followed and people living in the home were at risk of having their rights not respected and their liberty deprived without due processes being adhered to.

Staff were not consistently caring and care plans did not fully describe people’s needs or how they wished to be cared for.

We also found at this inspection that people were not supported to receive adequate food and drink which placed them at further risk from harm.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special

measures' by CQC. The purpose of special measures is to:

- Ensure that providers found to be providing inadequate care significantly improve.

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

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

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider's registration to remove this location or cancel the provider's registration.

There was a registered manager in post at the time of our inspection. This registered manager had been employed by the provider for eight months at the time of this inspection. A different registered manager was in post at the time of our previous inspection in June 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection in June 2016, we identified breaches of regulations 10, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to dignity and respect, the management of the service and staff training and support. At this inspection we followed up these breaches and found that the provider had not taken appropriate action to address all of our concerns. Breaches in respect of regulation 10, dignity and respect and regulation 17, good governance had not been addressed and we also identified additional breaches of Regulations 9, 11,12,13,17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at seven care plans. We found people’s needs and risks had not been properly assessed and managed. Information in relation to people’s care was confusing, contradictory and difficult to follow. It was difficult to determine from people’s care plans what their needs and risks were and the care they required. When we looked at the records in relation to people’s daily care we found gaps in the care people received. This meant there no consistent evidence that people received the support they needed.

The management of medication was not always safe and records showed that people did not always receive the medication they needed to maintain their well-being.

Accident and incidents records showed that support was not always provided in a safe way. Some people sustained injuries during the delivery of personal care and some accidents occurred as a result of faulty equipment. This did not show that the service provided safe care at all times.

We found that some incidents of a safeguarding nature had not been appropriately identified, responded to, documented or reported in accordance with local safeguarding procedures and the legal requirements of CQC. This meant the provider did not have a robust system in place to protect people from the risk of abuse.

Some of the people and the relatives we spoke with told us that there were not enough staff on duty to meet their needs at all times. We found that multiple incidents of a safeguarding nature and a significant number of accident and incidents had occurred as a result of people not receiving the level of support they required. This indicated that the number of staff on duty was not sufficient to ensure people were kept safe and well.

People’s ability to make decisions about their care had not always been assessed in accordance with the Mental Capacity Act 2005. For instance some people shared a bedroom with no evidence that they had consented to or had their capacity to consent to this living arrangement assessed to ensure it was in their best interests. We also saw that people had bed rails on their beds without evidence that they had consented to this or their capacity to consent to this decision explored. We found evidence to show good practice with regards to the application of the Mental Capacity Act for those people who needed to be deprived of their liberty to keep them safe.

Staff were observed to support people in a kind, patient manner but we found they did not always refer to people’s needs in a respectful or confidential way. For example, some staff referred to people who required support from staff at mealtimes as ‘feeders’ and some staff were overheard talking about people’s needs and care in front of the person and their peers. This did not show staff respected people’s right to have this information remain private.

People told us they got enough to eat and drink but people’s comments about the quality and choice of food on offer was mixed. We saw that lunchtime was a relaxed, unhurried affair. Two menu options were available for people to choose from and the chef told us that they often made alternatives to the menu for people who wanted something different. The chef had a good knowledge of people’s special dietary requirements.

Records showed staff were recruited safely and had received supervision in their job role. Staff appraisals and training were ongoing but improvements in both of these areas had been made since our last inspection.

The provider had audits in place to check the quality of the service but these were ineffective. For instance the inadequacy of people’s care planning information had not been picked up. Trends in accidents and incidents and incidents of a safeguarding nature had not been picked up and addressed. The provider’s medication audits failed to identify that the management of medication required improvement and there was no evidence that people views about the quality of the service had been sought.

This service was not well-led. At the end of our inspection, we discussed the concerns we identified during the inspection with the manager. They acknowledged and accepted the concerns we had raised with regards to the service.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

- Ensure that providers found to be providing inadequate care significantly improve.

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

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

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Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

The home had a manager who was registered with the Care Quality Commission. 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 and associated Regulations about how the service is run.

During the inspection we found a breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the end of this report.

During the day of our visit we saw that there were enough staff on duty and people did not have to wait for staff to attend to them. The rotas we looked at confirmed that these staffing levels were maintained by using agency staff as needed. Records we looked at did not show that new staff had received training before they started providing care for people. This meant that they may not know how to provide care in a safe manner.

The environment was light, spacious and airy. All parts of the premises were clean, hygienic and safe.

Deprivation of Liberty Safeguards (DoLS) had been applied for appropriately and were awaiting authorisation by the local authority.

We observed that staff members spoke to people in a polite and respectful way, however they did not always promote people’s dignity when they were providing care or in the language that was used in people’s care documents.

Family members visited during the day with no restrictions. Staff we spoke with had a good understanding and knowledge of people`s individual care needs. People we spoke with said that they were happy living at St George’s.

Care records we looked at showed that people’s care and support needs were assessed and planned for and the plans were reviewed monthly. However, care documentation was lacking in detail and the confidentiality of personal information was not always maintained.

We saw evidence that regular staff meetings and resident and relatives meetings took place. A significant number of satisfaction questionnaires had been circulated and returned during 2015. We saw records of a series of quality monitoring audits that were carried out. Although these systems were in place to find out people’s views and to monitor the quality of the service, there was no evidence to show how the information gained was used to identify and address any areas requiring improvement or to take the service forward.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

The premises were adequately maintained and regular health and safety checks were carried out. Robust recruitment procedures were followed to ensure that new staff were safe and suitable to work with vulnerable older people. Enough qualified and experienced staff were provided to ensure that people were kept safe.

Is the service effective?

People told us that they were happy with their care and that their needs were met. Staff we spoke with had a good understanding of people's care and support needs.

Is the service caring?

We observed that staff were kind and patient with the people who lived at the home and spoke about them in a positive and respectful manner.

Is the service responsive?

People's needs were assessed before they moved into the home. Care plans recorded people's personal preferences and interests, and care was provided in accordance with people's wishes. People had access to social activities.

Is the service well led?

The home had a new manager, who was a registered mental health nurse. The person who had previously been registered as manager of St George's had been promoted to an operations manager role and was supporting the new manager and visiting the home between two and four days each week. The home owner visited monthly and spoke with staff and people who lived at the home.

Another relative said that the staff were "smashing" and the new manager was 'very approachable'. She considered that the home was improving but she would not hesitate to raise any issues of concern.

One of the people we spoke with said 'I like the manager, she's nice, nothing is too much trouble. She mixes in with the staff and she has made a big difference.' Since our last visit to the home a relatives committee had been formed and one of their functions was supporting the families of people new to the home. The manager told us that she was keen to 'get everyone involved'.

The home owner visited the home at least once a month and spoke with the people who lived at the home and the staff during his visits. Since taking up post the manager had developed a series of audits covering all aspects of care and safety. These included monthly audits of medicines, care plans, wound care, weights, accidents and incidents, and complaints. We also saw records of fire safety audits, kitchen checks, and infection control audits.

There were 46 people living at the home. The number of care staff on duty had been increased to eight in a morning and six in an afternoon. This accommodated one to one support between 8am and 8pm each day for one person, and one to one support for two other people for three hours each day. The nurses we spoke with considered that this was adequate, however some of the care staff felt that they were very busy at some times of the day.

There was no senior person with a nursing or medical background to oversee the care of the people living at the home or to monitor the quality and relevance of the care plans. There was minimal evidence of any consultation with staff or people using the service and their families.