St Teresa's Nursing Home

St Teresa’s Nursing Home is a residential care home providing regulated activities accommodation for persons requiring nursing or personal care and treatment of disease, disorder or injury to up to 70 people. The service provides support to older people and people with dementia. At the time of our inspection there were 60 people using the service.

St Teresa’s incorporates a former nunnery with more modern, purpose built accommodation that is separated into 2 wings: Gainsborough and Bartelt. The service is laid out over 3 floors, bedrooms can be found on each floor, with some offering en-suite facilities. People have access to communal dining and lounging areas, including a recently installed sensory space. There is level access to large, well-stocked gardens and the registered manager’s office is located adjacent to the reception area.

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

Staff spoke confidently about protecting people from the risk of abuse. There were sufficient numbers of staff to keep people safe and staff received training relevant to people’s needs. Risk assessments were in place and provided guidance for staff. Infection prevention and control measures were implemented, and the service was visibly clean throughout. Overall, medicines were managed safely. In response to our feedback, the provider did implement additional cold storage for medicines and brought forward a planned meeting with an air conditioning technician, with the view of air conditioned medicines storage rooms.

We observed staff being kind and caring to people. People’s equality characteristics were respected, and different cultures were embraced. We observed staff maintaining people’s privacy by knocking on their doors prior to entering.

People were supported to eat and drink sufficiently; the dining experience had improved since our previous inspection. The layout of the premises had been reconfigured to aid the flow of care delivery. People were supported to access healthcare and professionals spoke positively about working with staff. We found people’s support with oral healthcare was inconsistent. The provider responded to our concerns and implemented a dental tracker at the time of our inspection. We did not find people experienced poor outcomes in relation to these inconsistencies. We received mixed comments from people about how consistently staff delivered care to support people’s choices.

People and relatives spoke positively about the registered manager and said they could raise concerns if needed. The provider continued to build relationships with local organisations and volunteers. Statutory notifications were submitted to CQC in line with regulations. Overall, audits and checks were used effectively to identify shortfalls, however we did find gaps in documentation that had not been identified by the provider checks.

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.

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 6 November 2020) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We inspected this service in line with current CQC priorities because the provider told us they had made significant improvements to care provision.

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.

This inspection was carried out to follow up on action we told the provider to take at the last inspection. 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 Teresa’s Nursing Home on our website at www.cqc.org.uk.

Recommendations

We have made one recommendation in relation to the consistency of governance systems.

Follow up

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

St Teresa's Nursing Home is a nursing home providing personal and nursing care for up to 70 people. At the time of the inspection 44 people were living at the home.

The home is laid out over three floors and areas within the home have been separated into three 'wings': Gainsborough Wing, Bartlet Wing and Austen Wing. People are placed on wings according to their needs, for example nursing or dementia care.

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

People and their relatives told us they felt safe at St Teresa’s Nursing home. Safeguarding incidents were reported to the appropriate agencies. Staff felt confident to raise safeguarding concerns with the registered manager and were aware of external agencies where they could report concerns.

Risks to people were identified and guidance was in place for staff to reduce the level of risk to people. Checks were in place to ensure the environment and equipment was safe. Infection control procedures were in place. Medicines were managed safely.

There were enough staff available to support people safely and meet their needs. Staff were recruited safely.

Governance systems were in place to monitor the quality of service and the health, safety and welfare of people. There were systems in place to communicate with people and relatives. We received some mixed feedback from relatives regarding the recent communication with the home.

Staff commented positively about the leadership and management of the home. Staff told us their morale was good.

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 inadequate (published 10 October 2019) and there were multiple breaches of regulation. At the last inspection we served a warning notice on the provider in relation to Regulation 12, Safe care and treatment. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse and improper treatment) and Regulation 18 (Registration Regulations 2009) (Notification of other incidents).

At this inspection we only reviewed the safe and well led key questions. This is because of our current methodology and risks related to COVID-19 meant we were not reviewing the breaches of regulations in the effective and responsive key questions.

This service has been in Special Measures since October 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check whether the service was meeting legal requirements relating to Regulation 12 (Safe care and treatment), Regulation 13 (Safeguarding service users from abuse) and Regulation 18 (Registration Regulations 2009) (Notification of incidents). This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. Our report is based on the findings in those areas at this inspection.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

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

Follow up

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

St Teresa’s Nursing Home is a nursing home and was providing personal and nursing care to 66 people aged 65 and over at the time of the inspection. The service can support up to 70 people.

The home is laid out over three floors and areas within the home have been separated into three ‘wings’: Gainsborough Wing, Bartelt Wing and Austen Wing. People are placed on wings according to their needs, for example nursing or dementia care. There are communal toilets and bathrooms located throughout each wing. Most rooms have en-suite facilities including a shower, hand-washing facilities and toilet. People have access to communal lounges and dining areas within the home. There is level access to a patio area with seating and tables and views across the garden. There are a number of smaller accessible outdoor spaces that are decked or patioed. The manager’s office is located close to the main entrance. There is parking available on site.

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

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

People were not always protected from the risk of avoidable harm and potential abuse. This was because assessment, guidance for staff, processes and practice were not always robust, comprehensive or safe. For example, safeguarding concerns were not always correctly identified and this meant the local safeguarding team were not always contacted appropriately. People told us there were insufficient numbers of staff to meet their needs, staff confirmed this. Environmental hazards were not consistently identified this meant actions were not taken to ensure the environment was safe for people. We also found gaps in records associated with the management and administration of medicines.

Peoples’ needs were not always assessed and when their needs changed assessments were not consistently reviewed. This included a lack of robust assessment regarding the use of air mattresses. People were not always supported by staff with relevant training and who had received regular supportive supervision sessions. When people lacked capacity to make a specific decision, capacity assessments did not always include information about the specific decision that needed to be made. Further ‘photograph consent forms’ were used inappropriately, for example relatives without Lasting Power of Attorney (LPA) signing on behalf of the person. For those who required it, food and fluid intake and targets were set and monitored appropriately.

Staff did not have sufficient time to provide unrushed care, however people told us they received support from staff who were caring. Staff spoke about people in a person-centred way. Information about people who required modified diets was displayed in communal areas and this was not dignified for people. On occasion, we observed a task focussed approach to providing people with care.

There were systemic failures in relation to oversight and audits of the service; audits had not been used effectively to identify concerns, errors and omissions we identified during the inspection. When audits had identified actions were required, plans did not always include relevant information, such as time frames and who was responsible for implementing changes. Peoples’ confidential information was not always stored securely and was accessible to people and visitors to the home. The provider did not always submit statutory notifications to the Commission as required, further notifications were not submitted ‘without delay’. People and staff spoke positively about the manager.

Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 14.

Fluid and food targets for people were being calculated correctly and monitored at appropriate intervals.

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 August 2018)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected: This was a planned inspection based on the previous rating.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Well-Led, Effective, Responsive and Safe sections of this full report.

The provider contacted us after the inspection and informed us about actions they would take to improve safety. Actions included auditing areas of concern highlighted during the inspection, having discussions with staff about relevant topics and providing opportunities for staff to access further training and information. An additional manager was allocated to the home to help drive improvement and improve monitoring of the service.

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

Enforcement

Since the last inspection we recognised that the provider had failed to ensure people received safe care and treatment. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

We have identified breaches in relation to health and safety, assessment, person-centred care and failure to work in accordance with the Mental Capacity Act (2005). The service was not well-led and this meant audits were not used effectively to identify errors and omissions. There was a further failure to ensure statutory notifications were consistently submitted to the commission and ‘without delay’.

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

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The home is registered to provide nursing and personal care for up to 70 older people accommodating people across three separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of the inspection 59 people were living at the service.

The inspection took place on 24 and 25 July 2018. The first day was unannounced.

At the previous inspection on 09 June 2016 we found improvements were required in recording the effectiveness of pain relief, pressure relieving mattresses, people’s dietary requirements and pressure ulcer dressing changes. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found some improvements had been made; however shortfalls still remained in relation to food and drink monitoring. This was because fluid intake targets had been calculated incorrectly. Charts we looked at did not show that people had enough to drink. Food monitoring charts did not detail what people had eaten. This meant staff would be unable to assess if people had received a nutritionally balanced diet. Other monitoring charts, such as position change charts had not always been completed in full.

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 2008 and associated Regulations about how the service is run.

Quality assurance systems did not always identify shortfalls found during this inspection. There were extensive quality assurance systems in place; however, the inaccurate monitoring of people’s fluid intake targets had not been identified during audits. Actions arising from audits had not always been completed within specified timeframes. Shortfalls such as recording of complaints and statutory notifications had not been consistently completed.

Staff had been trained to keep people safe. People using the service and their relatives told us they felt safe. Care plans contained risk assessments. When risks were identified the plans provided clear guidance for staff on how to reduce the risk of harm to people.

Incidents and accidents were reported and analysed to identify trends. There was evidence that lessons were learned when incidents happened.

Medicines were managed safely.

Comprehensive pre-assessments had been completed before people moved to the service.

Staff were trained to undertake their roles. Staff had regular supervisions with a supervisor.

People using the service spoke highly of the staff and all were happy with the support they received. We observed positive interactions between staff and people.

Care plans were person centred; however, end of life plans did not always reflect people’s choices and preferences.

Air mattress checks were in place and all of the mattresses we looked at were set correctly.

Complaints were logged. However, investigations and outcomes of complaints had not always been documented.

We received mixed feedback from people using the service about the activities available to them and the level of social interaction they received.

All of the staff told us the service was well managed. People using the service and their relatives gave positive feedback about the management team.

Although the majority of statutory notifications had been sent to the commission, one incident in relation to an allegation of verbal abuse had not.

We found one breach of the Regulations in 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 the report.

St Teresa’s Nursing Home is registered to provide nursing and personal care for up to 70 people. There were 68 people living in the home on the days of our visit. The home is divided into two units. The Gainsborough Unit accommodates up to 27 people, most of who are living with dementia. The Bartelt Unit accommodates up to 43 people who need general nursing care.

A third unit is currently being developed within the Bartelt Unit. This is called Austin Unit, and will provide accommodation for people living with dementia. The total number of people accommodated will not change.

There was a manager in post. They had applied and were in the process of completing the registered manager application process. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were assessed before they moved into the home to ensure their needs could be met.

Risks to people were assessed, and where identified, actions were taken to reduce the risks and keep people safe.

When we inspected on 5 and 12 March 2015 we found intervention charts such as fluid monitoring and positional change charts were not always completed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found sufficient improvements had been made.

We found improvements were required in recording the effectiveness of pain relief, pressure relieving mattress settings, people’s dietary requirements and pressure ulcer dressing changes.

People told us they experienced difficulties in their communication with some staff that were not able to communicate effectively because of their English language skills.

People received personalised care that was responsive to their needs. Care plans reflected that people’s individual needs, preferences and choices had been considered.

People were supported to have their nutritional needs met. The dining experience was relaxed, and people received the support they needed.

Governance systems were in place to monitor and mitigate the risks relating to the health, safety and welfare of people.

When we inspected on 5 and 12 March 2015 we found systems were not in place to obtain consent from people. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found improvements had been made. We found the rights of people who did not have the capacity to consent to care and treatment were protected because the service worked in accordance with the Mental Capacity Act 2005.

The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. Where people were deprived of their liberty this was done lawfully.

People who were supported by the service felt safe. Staff understood how to safeguard people, and knew the actions they would take if they suspected abuse.

We found one breach of the Health and Social Care Act 2008 Regulated Activities) Regulations 2014.

The focus of the inspection was to answer five key questions; is the service caring, responsive, safe, effective and well-led?

Below is a summary of what we found. The summary describes what people who used the service, their relatives and the staff told us, what we observed and the records we looked at.

If you would like to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service caring?

People looked well cared for. When we spoke with people they were complimentary about the care they received from staff, describing them as 'caring' and 'friendly'.

Staff respected people's privacy and were knowledgeable about the people they cared for. Staff were able to tell us about the people they supported, their likes and dislikes and their preferred care routines. One relative told us that they were very happy with the care their family member received. Prior to our inspection we had received information of concern in relation to people not receiving care as given in their care plan. We found this concern was unsubstantiated. We followed the care routines of six people and found that each person had received the care documented within their care plan.

Is the service responsive?

The home provided services for people with varying levels of need and records clearly demonstrated how care and support should be provided in line with people's wishes. There was a system in place to review the dependency needs of people and to change the level of support where required. Nursing staff reviewed and monitored people's care and treatment needs to ensure appropriate care was given in response to changing needs.

People's care and treatment was reviewed on a regular basis with them, this enabled people to discuss any changes or preferences regarding their care and support.

In the Gainsborough wing, people took part in activities if they wished to. In the Bartelt wing, the new activities co-ordinator was consulting with people about the activities they wanted to take part in. People told us they looked forward to this.

We found that there was a difference in the understanding and practice of some care workers in how they communicated with people. This particularly applied to those people who had a dementia or cognitive impairment and resulted in an inconsistent approach in how staff informed, involved and supported people with their care and treatment.

Is the service safe?

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found there were appropriate policies and procedures in place and staff we spoke with were confident of how the Mental Capacity Act 2005 and DoLS impacted on the people they supported. The provider had appropriate systems in place to ensure that best interest decisions were made in line with Regulation 4 of the Mental Capacity Act.

Quality audits were carried out to ensure a safe environment. The home was clean throughout and walkways were clutter free which enabled people to move around the home safely and freely. Medicine audits were undertaken to monitor and reduce potential risks. Incidents and accidents were responded to appropriately and the provider submitted notifications to the Care Quality Commission as required and reported relevant safeguarding concerns to the appropriate authorities.

Prior to this inspection we received information of concern around insufficient staffing. We did not find this to be the case. We found there were appropriate numbers of staff on duty to ensure that people received care in a timely manner.

Is the service effective?

The home had systems in place to ensure that people received the care they required. Care plans were person centred and demonstrated that people's care and treatment needs had been assessed and were reviewed on a regular basis. The nursing staff worked closely with other care staff in providing guidance when care and support needs changed which ensured a continuity of care.

People said they were happy that they received appropriate care and support. All care staff within the home were being offered specific training which was relevant to their role, such as dementia awareness.

Is the service well-led?

There were quality assurance processes in place which were monitored externally through the provider. There were audits in place and checks were made regarding the environment, record keeping, infection control, medicines, falls risks and complaints.

People told us they would inform the manager if they had any complaints. One person said "I have no complaints at all". There was a clear procedure in place where people or their families could raise concerns and information was available to people regarding the complaint process.

People were asked for their opinion on the service they received through satisfaction questionnaires. Staff were able to discuss concerns directly with the manager or through team meetings. Staff were aware of the structures in place regarding accountability and were confident in their role and responsibilities.

People who use the service and their families said that privacy, dignity and independence were respected and their views and experiences were taken into account in the way the service was provided. One person said, 'Everything is alright, I have no complaints'.

In addition people also expressed the view that before they received any care or treatment they were asked for their consent and St Teresa's staff acted in accordance with their wishes.

People said that care and treatment was planned and delivered in a way that ensured safety and welfare. A relative said, 'I think it's excellent, it's really good'. They said staff members noticed any little changes in the person's behaviour or condition.

People we spoke to all informed us that a choice of meals was always offered and expressed a high level of satisfaction to us with the food provided at St Teresa's; that it was nutritional and plentiful.

In the sample of records we checked, we did not find that the care plans for people who lacked the capacity to consent to them, were accompanied by a best interest decision which adhered fully to the requirements of the Mental Capacity Act.

One family member said, 'I think this is a very good nursing home; the care is excellent; there is care and compassion'.