Seaview Nursing Home

St Dominic’s Nursing Home provides nursing and personal care for up to 91 people with nursing needs, such as Parkinson's, diabetes, and heart failure, many of whom were also living with dementia. The home was divided into six units, over three floors, Fern, Crocus, Dahlia, Aster, Bluebell and Elderflower. Fern and Elderflower units remain closed currently. There were 43 people living at the home on the days of our inspection.

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

The governance systems had not supported the service to consistently improve and sustain improvement. Audit systems and processes had failed to identify risks to people's safety and other aspects of the service that required improvement.

Improvements had not been sustained since their last inspection and additional concerns were identified during this inspection in relation to staffing and person-centred care.

There was a lack of clear and accurate records regarding some people's care and support. For example, oral care, nutrition and fluid support, and peoples’ mental health. Some people’s care records were inaccurate and did not reflect their actual needs. There was a lack of oversight by the provider and management team.

Risk management was an area identified as needing improvement to ensure peoples’ health and well-being was protected and promoted. We identified shortfalls in respect of the risk of choking, management of dehydration, mental health guidance and the management of specific health problems. Staff practices regarding medicines needed to be further developed to ensure that staff follow the organisational policy for safe administration and recording of medicines. Peoples’ oral health was not consistently monitored to ensure good practice was consistently followed.

Staffing levels were not sufficient at this time to meet people’s individual needs to keep them safe and ensure their well-being.

We have made a recommendation about the mental capacity assessments for people who live at St Dominic’s Nursing Home.

People received care and support from staff who had been appropriately recruited and trained to recognise signs of abuse or risk and understood what to do to safely support people. People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible.

There were COVID-19 policies in place for visiting that was in line with government guidance. Families told us that they were welcomed into the home and followed the guidance currently in place. We signposted the provider to resources to develop their approach.

Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.

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

Rating at last inspection and update:

The last rating for this service was Requires Improvement (published 17 December 2021)

Why we inspected

This inspection was prompted due to information of risk and concern in relation to staffing levels, communication and safeguarding concerns which had impacted on care delivery. We also used this opportunity to look at the breaches of Regulation 12 and 17 from the last inspection in November 2021. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 remained requires improvement. This is based on the findings at this inspection.

The concerns raised were looked at during this inspection and have been reflected in the report.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led questions of this full report.

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.

Enforcement

We have identified continued breaches in relation to safe care and treatment, staffing and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up:

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

St Dominic’s Nursing Home provides nursing and personal care for up to 91 people with nursing needs, such as Parkinson's disease, diabetes, many of whom were also living with dementia. The home was divided into six units, over three floors, Fern, Crocus, Dahlia, Aster, Bluebell and Elderflower. Fern and Elderflower unit remain closed at this time. There were 43 people living at the home on the days of our inspection.

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

Systems and processes to assess, monitor and improve the quality and safety of the service provided were in place, and had improved since our last inspection. However, there were areas of people’s documentation that needed to be improved to ensure staff had the necessary up to date information to provide consistent, safe care. Staff practices regarding medicines needed to be further developed to ensure that staff follow the organisational policy for safe administration and recording of medicines. Peoples’ oral health was not consistently monitored to ensure good practice was consistently followed. Many people were not having oral care as they did not have toothbrushes or toothpaste.

A new computerised care document system had improved the content of care plans and risk assessments. However, the improvements had not been sustained due to changes in staffing and a high use of agency staff. There were some people who did not have sufficient information documented regarding their care needs to keep them safe and promote their well-being. Areas of risk management regarding high blood sugar levels and skin infections were not reflected with guidance for staff to follow.

People received safe care and support from staff who had been appropriately recruited and trained to recognise signs of abuse or risk and understood what to do to safely support people. One person said, “Good staff, but there are new faces and they don’t know us as well.” A visitor told us, “I have respect for the staff, they have kept going, through everything, we are pleased with the care.” People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. There were enough staff to meet people's needs, but further staff to deal with unexpected events would be beneficial, staff deployment at busy times needs to be reviewed. Safe recruitment practices had been followed before staff started working at the service.

There were COVID-19 policies in place for visiting that was in line with government guidance. Families told us that they were welcomed into the home and that staff supported them with the lateral flow test and personal protective equipment (PPE). We signposted the provider to resources to develop their approach.

Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.

The provider and registered manager were committed to continuously improve and had developed structures and plans to develop and consistently drive improvement within the service and maintain their care delivery to a good standard.

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

Rating at last inspection and update:

The last rating for this service was Requires Improvement (published 04 June 2019)

Why we inspected

This inspection was prompted due to information of risk and concern in relation to staffing levels, communication and safeguarding concerns which had impacted on care delivery. We also used this opportunity to look at the breaches of Regulation 12 and 17 from the last comprehensive inspection in June 2019. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

The concerns raised were looked at during this inspection and have been reflected in the report.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led questions of this full report.

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 intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

We found the following examples of good practice

Due to an outbreak of Covid-19, the home was currently following government guidance and was closed to visitors apart from those whose loved ones were on a palliative care pathway and receiving end of life care. Visitors at this time were asked to wear personal protective equipment (PPE), have a lateral flow test on arrival and have their temperature taken. This included health professionals.

Staff supported people to remain in contact with their families by phone and video calls whilst in isolation. There was a visiting policy to support visitors once the home re-opens to visitors. There was also a visiting room with a clear Perspex divider with an outside entrance where families will be able to meet their loved ones' safely.

The home has just re-opened for admissions. All new arrivals to the home will only be accepted with a negative polymerase chain reaction (PCR) test and will isolate for 14 days. There was now a dedicated isolation unit, with a separate staff team that will be used for all new arrivals for 14 days, before moving into the room of their choice within the premises.

There were systems in place to ensure that people who had tested positive for Covid-19 and self-isolating were cared for in their bedrooms to minimise the risk of spreading the virus. Staff were provided with adequate supplies of PPE and staff were seen to be wearing this appropriately. Staff had received specific Covid-19 training, and this included guidance for staff about how to put on and take off PPE safely. Updates and refresher training took place to ensure all staff followed the latest good practice guidance. They were seen to be following correct infection prevention and control practices (IPC). Hand sanitiser was readily available throughout the home.

The home was clean and well maintained. There was regular cleaning throughout the day, and this included high-touch areas. The housekeeping staff were knowledgeable regarding current Covid-19 cleaning guidelines and robust cleaning schedules were in place. The deputy manager was the infection lead for the home and undertook spot checks on staff practice. The registered manager also did daily walk rounds to observe and support staff and people.

Regular testing for people and staff was taking place. There had been changes to testing following their outbreak of Covid-19 as people and staff who tested positive were not tested for 90 days as per government guidance. Routinely all staff have a weekly PCR and twice weekly lateral flow test (LFT). In addition, they have their temperatures taken daily. People have a monthly PCR test with daily temperatures and oxygen level checks.

At present the majority of people chose to spend time in their rooms, staff however were supporting people to remain engaged with one to one activities. People who chose to visit the dining areas or communal areas were supported by staff to maintain social distancing. For example, chairs and tables had been re-arranged to allow more space between people.

We found the following examples of good practice.

The registered manager had ensured that all admissions from hospital were made safely and only following a test for COVID-19. The registered manager told us this had been their policy from the start of the pandemic, before it became government guidance.

The registered manager and staff had thought of various ways to keep people’s spirits up during the pandemic. This included assigning an activity worker to cut and style people’s hair in the absence of the hair-dresser.

Relative visits had just been reintroduced into the home. The registered manager was using a lounge on the empty floor to enable safe visits between people and their relatives. This lounge could be accessed through a separate entrance to the building. The registered manager had also identified an area on the bottom floor where five bedrooms could be used to isolate people if they should be diagnosed with COVID-19.

St Dominic’s Nursing Home provides nursing and personal care for up to 91 with nursing needs, such as Parkinson's, diabetes, and heart failure, many of whom were also living with dementia. The home was divided into six units, over three floors, Fern, Crocus, Dahlia, Aster, Bluebell and Elderflower. Fern unit was on the lower ground floor and was home for people living with complex dementia needs. Elderflower unit remained closed. There were 55 people living at the home on the days of our inspection.

People’s experience of using this service:

The providers’ governance systems had not identified the shortfalls found at this inspection.

There was a lack of clear and accurate records regarding some people's care and support.

The provider did not have an overview of staff training as the training programme was inaccurate and had not been updated. We found not all staff had had fire training and training in moving and handling.

Registered nurse competencies were not up to date according to the provider’s records.

People’s health, safety and well-being was not always protected, because not all people who lived at St Dominic’s Nursing Home had a specific care plan and risk assessment that reflected their identified needs, such as pressure sores, diabetes and bony injuries.

Weight loss and weight gain had not always been highlighted and there was no evidence that stated further action had been taken to mitigate people’s risk. Wound care was not always accurately documented and did not follow the person’s wound care plan. This meant that people's safety and welfare had not been adequately maintained at all times.

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

People’s nutritional needs had not always been met and the meal delivery had impacted on people’s meal time experience. Staff knew people’s likes and dislikes. Comments from people about the meals included, “Good food,” “I like the food” and “Not bad, large portions, plenty of food.”

There were sufficient staff to meet people’s individual needs: all of whom had passed robust recruitment procedures which ensured they were suitable for their role. However, the deployment of staff impacted on the care delivery. For example, on Fern unit there was no clear leadership and two inexperienced staff members were delivering care.

Whilst there were areas of care planning and assessing risk to people that needed to be improved, there were systems to monitor people's safety and promote their health and wellbeing, these included personalised health and social risk assessments and care plans for most people apart from the ones mentioned above.

The provider ensured that when things went wrong, these incidents and accidents were recorded, and lessons were learned.

People and relatives told us staff were ‘kind’ and ‘caring’. They could express their views about the service and provide feedback. One person said, “We are looked after very well and another said, “Really lovely staff.”

People were encouraged to live a fulfilled life with activities of their choosing and were supported to keep in contact with their families. One person told us. “Staff help me to ring my family, so I can keep in touch with them."

People’s care was designed to ensure their independence was encouraged and maintained. Staff supported people with their mobility and encouraged them to remain active.

People and families were involved in their care planning as much as possible. End of life care was planned for and staff confirmed they received training in this area.

Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT).

Notifications had been completed to inform CQC and other outside organisations when events occurred.

Staff told us there was a good workplace culture. One staff member said, “I enjoy working here, it’s not easy but the residents make it.”

The service met the characteristics for a rating of Requires Improvement. We found two breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This is not the first time that the service has been in breach of the regulations. The service had not been able to sustain the improvements made since the last inspection.

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

Rating at last inspection: Good. (Report published on 18 April 2018.)

Why we inspected:

This inspection was brought forward due to information of risk and concern. CQC received concerns in respect of staffing levels, lack of training, quality of food and care delivery. The concerns raised were looked at during this inspection and have been reflected in the report.

Follow up:

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

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve the key questions safe, effective, caring, responsive and well led to at least good. This inspection found that improvements had been sustained and the overall rating was ‘Good’. We will review the overall rating of good at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been sustained.

St Dominic’s Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. St Dominic’s Nursing Home provides accommodation and nursing care for up to 91 people, who have nursing needs, including poor mobility, diabetes, as well as those living with various stages of dementia.

St Dominic’s Nursing Home is registered to provide care to people with nursing needs, such as Parkinson’s, diabetes, and heart failure, many of whom were also living with dementia. The home was divided into six units, over three floors, Fern, Crocus, Dahlia, Aster, Bluebell and Elderflower. Fern unit was on the lower ground floor and was home to people living with complex dementia needs. Elderflower unit remained closed. There were 53 people living at the home on the days of our inspection.

There was a registered manager in post. 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.

This inspection found that the provider had continued to progress quality assurance systems to review the support and care provided. This included undertaking root core analysis on events that affect people at the service and reflective learning from safeguardings, incident and complaints. Root cause analysisis a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems. Audits included those for accidents and incidents, care plans, medicines and health and safety.

The overall rating for St Dominic’s Nursing Home has been changed to good. We will review the overall rating of good at the next comprehensive inspection, where we will look at all aspects of the service and to ensure the improvements have been sustained.

People were safe at the service. Staff knew how to identify abuse and understood the safeguarding procedures to follow to protect people from abuse. Risks to people's health and well-being were assessed and managed. There were appropriate risk management systems which ensured staff delivered safe care. People's needs were met in a safe and timely manner by a sufficient number of staff. The provider followed appropriate recruitment procedures to ensure they employed staff who were suitable to provide care. People received their medicines when needed. Medicines were administered and managed safely by staff who were trained to perform that role.

Staff received the training necessary to provide safe and effective care. People were supported to eat a healthy and nutritious diet. Food and fluid charts were completed when risk of poor eating and drinking had been identified. These showed people were supported to eat and drink. Staff and the registered manager had a good understanding of the Mental Capacity Act. Where possible, they supported people to make their own decisions and sought consent before delivering care and support. Where people's care plans contained restrictions on their liberty, applications for legal authorisation had been sent to the relevant authorities as required by the legislation.

Health and social care professionals were involved in the planning and reviewing of people's care to ensure support provided met best practice guidance and legislation. Staff had a good understanding of people's needs and treated them with respect and protected their dignity when supporting them.

Staff provided care that was responsive to people's needs. Lessons were learnt from incidents and accidents to minimise a recurrence. A range of activities were available for people to participate in if they wished and plans to develop activities were in progress. Staff had received training in end of life care supported by the local Hospice team. Visits from healthcare professionals were recorded in people’s care plans, together with information about any changes and guidance for staff to ensure people's needs were met. The service worked well with external health professionals.

Staff said the management team was fair, care meetings were held every morning to discuss people's changing needs and inform staff. Staff meetings were held monthly and staff were able to contribute to the meetings and make suggestions.

St Dominic’s Nursing Home is registered to provide care to people with nursing needs, such as Parkinson’s, diabetes, and heart failure, many of whom were also living with dementia. The home was divided into six units over three floors, Fern, Crocus, Dahlia, Aster and Bluebell and Elderflower. Fern unit was on the lower ground floor and was home to people living with complex dementia needs. Elderflower unit is still closed at this time. The home can provide care and support for up to 91 people. There were 45 people living at the home on the days of our inspection.

There was a registered manager in post. 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.

At a comprehensive inspection in November 2014 we rated this service as inadequate and took enforcement action. Breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by January 2015. During our inspection in February and March 2015, improvements had been made and breaches in regulation had been met. Due to concerns raised with us we inspected in September 2016 where we found that improvements made in February and March 2015 had not been sustained. People’s safety was compromised in a number of areas. The overall rating for the service was Inadequate and the service was placed into special measures by the Care Quality Commission (CQC). Seven breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified and we took enforcement action.

In September 2016 people had not been protected against unsafe treatment by the quality assurance systems in place. There were also concerns relating to the management and leadership of the practice, specifically in the well led domain. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance. Due to further concerns we received in December 2016 we undertook a focussed inspection to look at peoples’ safety. We found that there had been improvements made. The concerns raised with us were not fully substantiated and that people’s health and safety was at that time assured by the deployment and experience of staff.

On 12 and 13 March 2017 we found that whilst there were areas still to improve and embed in to everyday practice, there had been significant progress made. The history of the service has demonstrated that they have not been able to sustain improvements in the past. The service has been taken out of special measures and there are no breaches of regulation. We have rated this service as Requires Improvement overall and at the next inspection we will check to make sure the improvements are embedded and sustained. This is because we will need to see that as more people come to live at the service, the improvements are continued.

Care plans reflected people’s assessed level of care needs and were based on people's care needs. However further development was needed to ensure that the care reflected people’s specific changed health and social care needs. Whilst there were activities provided Monday to Friday, they did not reflect everyone’s interests and some people in their bedrooms received little interaction.

Mental capacity assessments whilst undertaken were not always decision specific. A clear rationale for continuous bed rest for individual people needed to be developed to ensure that it was in people’s best interests.

We saw some very nice interactions between people and the staff working in St Dominic’s Nursing Home. However we also saw some staff did not always treat everyone with respect or maintain people’s privacy. This was because they did not always knock on doors before entering their bed room despite knowing they had visitors.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider, manager and staff had an understanding of their responsibilities and processes of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Staff handovers and communication systems had improved and were informative to care changes. Risk assessments that guided staff to promote people’s comfort, nutrition, skin integrity and the prevention of pressure damage were in place and accurate. There were behavioural management plans in place for those people who lived with behaviours that were challenging. People identified at risk from pressure damage had the necessary equipment in place to prevent skin damage and this was set correctly to meet their individual needs.

Staff had a good understanding of people's needs and treated them with respect and protected their dignity when supporting them. People were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and they responded to staff with smiles.

People were protected against the risks of unsafe medicines management. The staff were following current and relevant medicines guidance. We found that previous issues with how medicines were managed and recorded had been monitored and improved.

Staffing deployment ensured people received the support required to ensure their health and social needs were met. There were arrangements for the supervision and appraisal of staff. Staff supervision took place to discuss specific concerns. Staff confirmed that they had regular supervision and yearly appraisals. People we spoke with were complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff were respectful to people and there was plenty of chat and laughter heard.

People were supported to eat and drink in a safe and dignified manner. The meal delivery ensured peoples nutritional and hydration needs had been met and offered a wide range of choice and variety of nutritious food.

The home was clean and well presented. Risks associated with the cleanliness of the environment and equipment had been identified and managed effectively. Emergency procedures were in place in the event of fire or evacuation.

People had access to appropriate healthcare professionals. Staff told us how they would contact the GP if they had concerns about people’s health.

The provider had progressed quality assurance systems to review the support and care provided. A number of audits had been developed including those for accidents and incidents, care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service and relatives told us they could visit at any time and, they were always made to feel welcome and involved in the care provided.

All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns, and they had a clear understanding of making referrals to the local authority and CQC. Pre-employment checks for staff were completed, which meant only suitable staff were working in the home. People said they felt comfortable and at ease with staff and relatives felt people were safe.

Staff said the management was fair and approachable, care meetings were held every morning to discuss people's changing needs and how staff would meet these. Staff meetings were held monthly and staff were able to contribute to the meetings and make suggestions. Relatives said the management was very good; the registered manager was always available and, they would be happy to talk to them if they had any concerns.

We carried out an unannounced comprehensive inspection of this service on 9,12 and 14 September 2016. The inspection showed that improvements had not been sustained and we found seven breaches of Regulation. The appropriate regulatory response is being considered.

After that inspection we received new information of concerns in relation to people’s health needs not being met and lack of suitably qualified and experienced staff. As a result we undertook a focused inspection 5 December 2016 to look into those concerns and ensure people’s immediate safety. This report only covers our findings in relation to the Safe question. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Dominic’s Nursing Home on our website at www.cqc.org.uk

A registered manager was in post. 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.

We found improvements in managing people’s health needs, such as wound care, diabetes management and promotion of skin integrity had been made. However we found that some elements of Regulation 12 (safe care and treatment) were not yet embedded in to everyday practice to ensure consistent safe care and treatment. For example, the safe use of pressure relieving equipment.

The staffing levels were consistent but we saw that at times the deployment of staff had impacted on care delivery. For example call bell response times meant people had to wait for assistance. People were not always appropriately supervised in a communal area that had electrical kitchen items left out with trailing wires and hot water. .

The use of agency staff had reduced as new staff had been employed. We were told that experienced clinical leads were due to start full time employment in December 2016.

We met some new staff that had recently been employed and were impressed with their enthusiasm and their commitment to the people they supported. We also found that staff that had worked at St Dominic's Nursing Home over the past year (and more) were committed to the improvements.

It was clear that the organisation was committed to improve the service and more time was needed to fully embed the improvements to care delivery and build up the staff team. This will be reviewed at our next comprehensive inspection which will be in the New Year.

The overall rating for this provider remains 'Inadequate'. This means that it continues to be 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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

St Dominic’s Nursing Home is registered to provide care to people with nursing needs, such as Parkinson’s, diabetes, and heart failure, many of whom were also living with dementia. The home was divided into six units over three floors, Fern, Crocus, Dahlia, Aster and Bluebell and Elderflower. Fern unit was on the lower ground floor and was home to people living with complex dementia needs. The home can provide care and support for up to 91 people. There were 73 people living at the home on the days of our inspection.

There was a registered manager in post. A registered manager had recently been transferred from another home in the organisation and was in their third week at St Dominic's Nursing 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 and associated regulations about how the service is run.

The comprehensive inspection in November 2014 rated this service as inadequate. At this time we took enforcement action. Breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. We found significant risks due to people not receiving appropriate person centred care. Where people’s health needs had changed considerably, care plans had not been updated. Staff did not have the most up to date information about people’s health. This meant there was a risk that people’s health could deteriorate and go unnoticed. Risk assessments did not reflect people’s changing needs in respect of wounds and pressure damage. Accidents and incidents had not been recorded appropriately and steps had not been taken by the staff to minimise the risk of similar events happening in the future. People had not been protected against unsafe treatment by the quality assurance systems. We also found that training had not been delivered where identified and administrative processes to support training, staff supervision and appraisal were inaccurate and incomplete. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance by January 2015.

During our inspection in February and March 2015, we looked to see if improvements had been made. The inspection found that improvements had been made and breaches in regulation had been met.

Due to a high number of concerns raised about the safety of people, the meal service and staffing levels we brought the scheduled inspection forward, so we could ensure that people were safe.

This inspection found that people’s safety was being compromised in a number of areas. Care plans did not reflect people’s assessed level of care needs and care delivery was not person specific or holistic. We found that people with specific health problems such as diabetes, kidney problems, and wounds were not up to date and did not have sufficient guidance in place for staff to deliver safe treatment. The lack of suitably qualified and experienced staff impacted on the care delivery and staff were under pressure to deliver care in a timely fashion. Shortcuts in care delivery were identified particularly in respect of personal care. We also found the provider was not meeting the requirements of the Mental Capacity Act (MCA) 2005. Mental capacity assessments were not completed in line with legal requirements. Staff were not always following the principles of the MCA. There were restrictions imposed on people that did not consider their ability to make individual decisions for themselves, as required under the MCA Code of Practice. There was confusion over whether deprivation of liberty safeguards (DoLS) were in place for people. The management list of DoLS was not up to date or accurate.

The delivery of care suited staff routine rather than individual choice. Care plans lacked sufficient information on people’s likes and dislikes. Information in respect of people’s lifestyle choices was not readily available for staff. The lack of meaningful activities impacted negatively on people’s well-being.

People, staff and visitors were not always complimentary about the meal service at St Dominic’s Nursing Home. The dining experience was not a social and enjoyable experience for people on all units. People were not always supported to eat and drink enough to meet their needs.

Quality assurance systems were in place but had not identified the shortfalls in care delivery and record keeping. We could not be assured that accidents and incidents were consistently investigated with a robust action plan to prevent a re-occurrence.

People’s medicines were not always stored safely and in line with legal requirements. There were gaps found in the recording of medicines of topical creams, dietary supplements and ‘as required’ PRN medication. Shortfalls identified by the pharmacy provider were still outstanding and had not been actioned by staff.

People and visitors we spoke with were complimentary about the caring nature of some of the staff. However the constant changes to staff, use of agency staff and staff leaving had impacted on how the home was run. Many people were supported with little verbal interaction, and many spent time isolated in their rooms.

Staff told us they thought that communication systems needed to be improved and they required more support to deliver good care. They felt that the lack of permanent staff and high staff turnover had raised issues. Their comments included, “Staff leaving and not showing up for work has been really difficult, we don’t always know who is supposed to be on duty.”

People had access to appropriate healthcare professionals. Staff told us how they would contact the GP if they had concerns about people’s health. However care plans did not include all the information about people’s health related needs.

People were protected, as far as possible, by a safe recruitment system. Each staff file had a completed application form listing their work history as wells as their skills and qualifications. Nurses employed by St Dominic’s Nursing Home and bank nurses all had registration with the nursing midwifery council (NMC), which was up to date.

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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Below is a summary of what we have found. The summary is based on our observations during the inspection. We observed the care provided, looked at supporting care documentation, staff records and records relating to the management of the service.

We spoke individually with the manager, deputy manager, four senior care staff, five care staff and one visiting health professional. The manager had been in post for eight months and has submitted their application to be registered by the CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

We also spoke with 12 people who used the service and five visitors.

Is the service safe?

People told us they were safe in the service. Comments received included, 'They help me when I need anything,' and 'I have just been happy here. I have been safe and they have looked after me.' One visitor said, 'I have confidence in the home, they care.' Another visitor said, 'I think things are okay, I do ask questions and check that food has been eaten and I visit very regularly, I have complained before but I can honestly say, things are better not perfect, but better.'

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Staff had received training but lacked understanding of their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However the management team knew who to contact should further guidance and support be required to ensure people's best interests. People had been asked for their consent for care or treatment but we saw that some consent documentation lacked signatures of the Power of Attorney(POA) and some people who lacked capacity had not had a mental health capacity assessment. A compliance action has been set and the provider must tell us how they plan to improve.

There were clear systems in place to make sure that the provider, management and care staff learnt from events such as incidents and accidents and concerns.

Staff training was available to undertake their roles in the service. We saw that systems to track training and refresher courses had been developed and monitoring systems put in place. This ensured that people were protected from unnecessary risk.

There were enough qualified, skilled and experienced staff to meet people's needs. During the inspection we saw that were able to meet people's physical needs in a timely manner.

Is the service effective?

People's health and care needs had not been consistently reviewed and updated. Their specialist care needs such as dietary requirements and support needs had not been clearly identified and followed through with a plan of action for staff to follow. This had not ensured safe and consistent care had been provided. Up-to-date guidance for staff to meet some people's needs, were not in place for staff to follow. This had meant this people were not receiving the care delivery required and placed them at risk from uninformed staff. We have asked the provider to take immediate action.

Is the service caring?

People were seen at times to be supported by kind and attentive staff and we saw that staff had some good relationships with people. We saw that care staff showed patience and offered encouragement when supporting people. Comments received included, 'Great staff and food.' 'Staff are kind,' 'They are sweet to me,' and 'Yes they are very good.' We saw that staff were kind and treated people with respect and courtesy.

People's preferences and diverse needs had not been identified within individual documentation. This meant new staff would not be able to provide person centred care. Not all care and support delivery was supported by evidence that it had been provided in accordance with people's wishes.

Is the service responsive?

People's needs had been assessed before they moved into the home. People told us that staff discussed any changes to do with their care with them regularly, and that staff were approachable if there were any issues of concern. There was evidence that the admission process for respite care had not been followed and lacked certain assessments and care plans to deliver responsive care.

There was a complaints policy and procedure in place if people or their representatives were unhappy, which was monitored by the provider. People told us they had not had to raise any concerns, and they were aware who to speak with if they had any concerns they said they felt they would be listened to. People could therefore be assured that complaints were investigated and action taken as necessary.

Is the service well lead?

We were told that there was a strong management team in place that were working together to improve the service. Staff told us, 'I feel we have support from both the manager and deputy,' and 'Much better, we work as a team.'

The service had quality assurance systems to develop and improve the service provided. However we identified shortfalls in care plans, risk assessments and maintenance of the premises that demonstrated the audits were not effective at this time. A compliance action has been set in relation to the quality assurance systems and management of risks and the provider must tell us how they plan to improve.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the service and quality assurance processes that were in place. This helped to ensure that the home was continually trying to improve.

Below is a summary of what we have found. The summary is based on our observations during the inspection. We observed the care provided, looked at supporting care documentation, staff records and records relating to the management of the service. The newly appointed manager has been in post for six months and has applied to be registered with the CQC and is referred to as manager in the report.

We spoke individually with the manager, two registered nurses, an activity coordinator, a senior care worker, two care workers and a new care worker who was shadowing, a domestic assistant and the cook. We spoke with twelve people who used the service and four visitors.

Is the service safe?

People were treated with respect and dignity by staff. People told us they were safe in the service. Comments received included, 'They help me when I need anything,' and 'I have just been happy here. I have been safe and they have looked after me.' One visitor said, 'I have confidence in the home, they care.' Another visitor said, 'I am not impressed at all, I have had to ask them to do basic care, not good enough.'

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. A compliance action has been set in relation to the management of medicines and the provider must tell us how they plan to improve.

People who used the service, staff and visitors were not fully protected against the risks of unsafe or unsuitable premises. We found shortfalls in the maintenance of some areas of the home. A compliance action has been set in relation to the maintenance of the service and the provider must tell us how they plan to improve.

Staff had received training and had an understanding of their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They knew who to contact should further guidance and support be required to ensure people's best interests. People had been asked for their consent for any care or treatment.

There was a system in place to make sure that the provider, management and care staff learnt from events such as incidents and accidents, complaints, and concerns.

Staff training was available to access to undertake their roles in the service. We saw that systems to track training and refresher courses had been developed and monitoring systems put in place. This helped to ensure people were not put at any unnecessary risk.

A recent decrease of staffing levels due to reduced occupancy of the service was noted by us at the beginning of the inspection. Following discussion with the management team we were told the staffing levels would be reverted back within 24 hours to reflect people's needs and not the occupancy levels. A compliance action has been set in relation to the staffing levels and the provider must tell us how they plan to improve.

Is the service effective?

People's health and care needs had been reviewed and where possible people and their representatives had been involved in the writing and review of the care documentation. Their specialist care needs such as dietary requirements and support needs had been identified.

However, no initial care plans and baseline risk assessment documentation was in place for one person. This had not ensured safe and consistent care had been provided, and up-to-date guidance for staff to meet this person's needs was not in place for staff to follow. This had meant this person was not receiving the care delivery required and placed them at risk from uninformed staff. We also found incomplete records for fluid and food intake. A compliance action has been set in relation to inadequate care delivery and records and the provider must tell us how they plan to improve.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and offered encouragement when supporting people. Comments received included, 'They help me when I need anything. They are very good and kind,' They are pretty good,' 'They are very kind,' and 'Yes they are very good.' We saw that staff were kind and treated people with respect and courtesy.

People had been not been asked to complete quality assurance satisfaction surveys.

People's preferences and diverse needs had been identified. People told us care and support had been provided in accordance with people's wishes.

Is the service responsive?

People's needs had been assessed before they moved into the home. People told us that staff discussed any changes to do with their care with them regularly, and that staff were approachable if there were any issues of concern. Records confirmed people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that met their wishes. One visitor told us, 'They regularly consult with me in respect of my X care as my X cannot tell them anything due to their dementia.' Another visor said, 'They haven't listened to us at all, I have had to keep on asking them to do things to ensure my X is comfortable.'

There was a complaints policy and procedure in place if people or their representatives were unhappy, which was monitored by the provider. People told us they had not had to raise any concerns, and they were aware who to speak with if they had any concerns They said they felt they would be listened to. People could therefore be assured that complaints were investigated and action taken as necessary.

Is the service well lead?

We were told that there was a strong management team in place that were working together to improve the service. However we found that when the management team was not in the home, care plan documentation had not been completed. We also found shortfalls in the cleaning of the home and clearing of recently vacated rooms.

The service had quality assurance systems to develop and improve the service provided. However we identified shortfalls in medication records care plans and maintenance of the premises that demonstrated the audits were not effective at this time. A compliance action has been set in relation to the quality assurance systems and management of risks and the provider must tell us how they plan to improve.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the service and quality assurance processes were in place. This helped to ensure that the home was continually trying to improve.

Care plans and delivery of care for people was person centred. The care we observed was in line with people's main care plan.

People were supported to eat and drink sufficient amounts of suitable and nutritious food and fluids to meet their needs. The new meal service was still being refined but we were told that the early reviews were positive from the people who used the service and visitors.

There were enough qualified, skilled and experienced staff to meet people's needs on five of the six units.

The provider had effective systems in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

We found that people's personal records, were not all accurate or updated

Care plans and delivery of care for some people was more task orientated than person centred. Not all care plans had been reviewed regularly to reflect people's health and well-being changes.

People were not always supported to eat and drink sufficient amounts of suitable and nutritious food and fluids to meet their needs.

There were not enough qualified, skilled and experienced staff to meet people's needs.

The provider did not have effective systems in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others

We found there were enough qualified, skilled and experienced staff to meet people's needs. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

During our inspection we found that most people were involved in decisions made about the care they received. We saw that the provider had robust recruitment procedures to follow for new staff. However, not all staff were receiving meaningful supervision. Documentation in people's care files had not been completed correctly, with gaps and inconsistencies seen.

By direct observation we found that call bells were not answered in a timely manner. We also saw that people were left unsupervised in communal areas without access to a call bell. We found that the skill mix and experience of staff had impacted on positive outcomes for people who used the service The provider could not evidence that there were enough qualified, skilled and experienced staff to meet people's needs.