Archived: St Margarets Residential Care Home

The provider is registered as a partnership. However, following the death of one of the two partners, an application has been made to CQC to re-register the service as a new partnership. This process was still in progress at the time of this inspection.

The home had 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.

At our previous inspection on 11 October 2016, we identified breaches of eight regulations. We issued warning notices requiring the provider to become compliant with regulations relating to consent to care and good governance by 10 January 2017. We also issued requirement notices requiring the provider to take action in relation to the registration of the service; person-centred care; safe care and treatment; staffing; openness and transparency; and the display of their performance rating.

At this inspection, we found some improvements had been made, but further improvement was required.

The provider had not met the requirements of the two warning notices we issued. They had not completed assessments of people’s capacity to make decisions or recorded decisions they had made on behalf of people. However, they had provided additional training to enable staff to do this.

The provider had not put an effective system in place to assess, monitor and improve the quality of the service overall. However, some individual issues highlighted in our warning notice relating to good governance had been addressed; for example, fire safety checks had been completed and action had been taken to meet the needs of people with diabetes.

Two issues we identified at the last inspection, relating to the security of medicines and the care of a person with a catheter (a device used to drain a person’s bladder through a flexible tube linked to an external bag) were only addressed during the inspection, after we raised them for a second time.

Individual risks to people were not always managed safely. Risk assessments had been completed for some, but not all the people who were potentially at risk of pressure injuries; and a person’s risk assessments was not reviewed when they experienced multiple falls. However, environmental risks were managed appropriately.

People told us they felt safe and staff knew how to identify, prevent and report incidents of abuse, although not all staff had attended refresher training in safeguarding, in accordance with the provider’s policy.

Medicines were not always managed safely. Checks of the competency and understanding of staff who administered medicines had not been completed.

There was no clear induction process in place to ensure that new staff were sufficiently competent to work alone. Experienced staff had completed additional training, although their training workbooks had not been marked to confirm that they had understood the training.

Managers had started to conduct appraisals with some staff, but staff did not have access to regular sessions of supervision. While most staff said they felt supported by their managers, some staff felt communication could be improved to ensure information about people’s well-being was shared effectively. They also felt the registered manager was not sufficiently visible around the home to provide the necessary guidance and direction.

People were satisfied with the quality of the food; although some people did not receive consistent support to make sure they ate and drank enough. Staff monitored people’s weight and took action if there was unplanned weight loss.

Some staff did not actively listen to people or treat them with consideration. However, most people told us staff were kind and caring and we observed some positive interactions between people and staff.

Activities were limited to an hour a day and were not run consistently, although the home was involved in an initiative with a school and people enjoyed interacting with pupils who visited.

There were enough staff to meet people’s essential care needs and recruitment processes helped ensure only suitable staff were employed.

Staff protected people’s privacy and dignity, including when they provided personal care, and confidential information was kept secure. People were encouraged to remain as independent as possible.

People were encouraged to make as many choices as possible about their day-to-day lives. They were supported to access healthcare services when needed and were involved in planning the care they received. The registered manager sought and acted on feedback from people.

Staff were more positive about the service than at our last inspection. They had been given enhanced roles and responsibilities, which the registered manager assured us would be “meaningful”.

We identified three breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The home had 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.

The provider is registered as a partnership. Providers are required to notify us of any changes affecting the partnership. However, they did not notify us of the death of one of the partners and the appointment of a new partner in 2013. Providers are also required to display their CQC performance rating. Whilst they had displayed this on the premises, they had not displayed it on their website, as required.

At our previous inspection in August 2015, we found staff were not following legislation designed to protect people’s rights. We asked the provider to write to us detailing how they would become compliant with the regulations. They did not do this and we found they had not taken appropriate action to ensure people’s rights were protected. Staff were continuing to make decisions on behalf of people but had not assessed whether these were necessary or in the best interests of people.

There was a quality assurance process in place, but this was not always effective in maintaining and improving the quality and safety of the service. Although people felt the home was run well, staff told us they did not work well together and suffered from low morale. This had affected communication between them to the detriment of people living at the home.

We found people’s safety was compromised in some areas. For example, fire safety checks had not been completed for the previous three months, so the provider was unable to confirm that they were operating correctly.

People’s medicines were not always managed safely as some medicines were not stored appropriately; information was not always available to inform staff when to administer ‘as required’ medicines; and the competence of staff to administer medicines was not assessed regularly, as recommended by best practice guidance.

Whilst there were sufficient staff to meet people’s needs at most times, this was not always the case at weekends. However, senior staff said there were plans in place to address this.

Staff were not supported to undertake appropriate training to ensure they had the necessary skills to meet people’s needs. Some staff who administered medicines had not their training refreshed for over three years; practical training in supporting people to move safely had not been refreshed for over a year; the food hygiene certificates of staff who prepared meals for people had expired; and induction training for new staff was not robust.

People said they were satisfied with the meals provided, but we found some people’s dietary needs were not always met. Menus were not available and meals were not planned to help ensure people received a healthy, balanced diet; and people who required a low-sugar diet did not always receive it. Although most people were weighed regularly, staff did not take appropriate action when people were found to have lost weight.

People told us their needs were met in a personalised way, but we found for some people this was not always the case. The care needs of a person with a catheter were not always met as staff did not monitor it effectively and their care plan did not provide supporting information. Similarly, the care plans for three people with diabetes did not provide enough information to enable staff to support them effectively; as a result, staff had not taken action when one person’s blood sugar levels were found to be particularly high.

Activity provision was limited and activities had not been tailored to meet the individual interests of people. However, work was on-going to improve this.

People, their families and healthcare professionals said they were satisfied with the care provided to people and felt their needs were met. Staff supported people to access healthcare professionals and provided supporting information if they were admitted to hospital. Staff were skilled at communicating with people living with dementia and people were supported and encouraged to make choices about how and where they spent their day.

The process used to recruit staff was safe. Staff knew how to protect people from the risk of abuse. People were supported to take risks that helped them retain their independence and avoid unnecessary restrictions.

People told us they were cared for with kindness and compassion by staff who interacted with them positively. Their privacy and dignity were protected at all times. People were encouraged to remain as independent as possible and they (or their family members) were involved in planning their care.

The provider sought and acted on feedback from people. People felt senior staff were approachable and any concerns would be dealt with. However, information about the provider’s complaints procedure was not always made available to people.

We identified several breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.

We looked at the provider's process for assessing the quality of the service, such as identifying risks of inappropriate care. We reviewed their internal audit system and assessments of health and safety risks, audits of care and incidents and accidents. We spoke with two staff members and the manager. We used the information to answer the question we always ask;

Is the service well-led

This is a summary of what we found;

Is the service well-led?

The service was not always well led as systems and processes to underpin safe and effective practices were not fully developed. There was a system to look at the safety of equipment which was serviced regularly. The auditing process did not regularly assess and monitor the quality of service provided. An infection control audit had not been fully developed. Care plans and medicines audits were not effective. Although risks were assessed; incidents and accidents were not looked at. It was not evident how learning from incidents and accidents took place in order for appropriate changes to be implemented. These meant shortfalls were not always identified and remedial actions taken.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing risks, incidents and accidents as part of the service provision.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found.

Is the service safe?

There were enough staff on duty to meet people's needs in a safe way and according to their needs. People were cared for in an environment that was clean and hygienic. Systems were in place to ensure the home was maintained in a satisfactory condition and equipment was serviced regularly.

Staff had completed training in the safeguarding of vulnerable adults. They could describe different types of abuse and action they would take to ensure people were safeguarded. They were aware of the local safeguarding procedures and information was displayed at the service. Risks to people's health and safety and mobility had been assessed and management plans were in place to reduce these risks.

Is the service effective?

People we spoke with told us they were 'more than satisfied' with their care and support. The staff sought professional help for people as needed to support their care needs. We saw staff supporting people with their meals at a leisurely pace and interacted positively with them. Care was not rushed and it was evident staff had developed friendly relationship with people living at the home. People's needs including their mobility were considered as part of providing care and adaptations such as hand rails and assisted bathing facilities were available to them.

Is the service caring?

We observed the staff showed an attentive and caring attitude towards people when providing care and support. People were treated with care and respect. A relative told us 'the staff are very caring and treat them all with respect'. People were offered choices and these were respected. A visitor told us they were 'very happy with the care their relative was receiving'. They said 'my sister has always been a happy person and she remains happy here'. People told us the staff were 'very kind' and we observed staff were responsive to people's needs.

Is the service responsive?

An assessment was completed prior to people moving into the home to ensure their needs could be met. Where risks had been identified such as pressure injury and fall, care plans had been developed and equipment put in place to manage these effectively. Changing needs of people were monitored and action taken such as referral to dietician and mental health team.

Is the service well-led?

There was a system to seek views of people using the service. Risks were assessed and appropriate action plans were in place. There was no developed auditing system in place in order to look at shortfalls in service delivery. Action was taken following falls and referral was made to fall clinics. However the provider did not have a process in place to review and learn from incidents, accidents and complaints. There was no infection control, care plans and medicines audits in place to assess the quality of care and risks in order to protect people who use services and others who may be at risk.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance, auditing of care and learning from incidents and accidents.

We spoke with one family member who was visiting their relative. They described the service as 'homely and friendly'. They told us their relative received care and support which met their needs. They considered appropriate food and drink were provided and the home was kept clean.

We observed the care and support given to people in the communal areas of the home. We saw staff were friendly and caring, aware of people's needs and preferences, and responsive to them.

We spoke with staff and reviewed records related to people's care and the management of the service. We found people's care needs were assessed and their care plans reflected their assessments. People's nutritional needs were met. There were sufficient staff to provide the necessary care and support.

However we found policies, procedures and risk assessments relating to the prevention of infectious diseases did not meet current guidance. Records relating to the management of the service were out of date and could not be located promptly.

We also spoke with a visitor who said their relative's needs had been assessed and that their care was delivered according to agreed plans. They described the home as having a 'friendly, open atmosphere' and said their relative 'seems happy here'.

We found that people's consent was obtained before care was delivered. If there was any doubt about their ability to consent, family members and other healthcare professionals were consulted. People's care needs were assessed and their care plans and the care delivered reflected their needs. We saw that medicines were administered and stored appropriately. We found that the necessary checks were made before employees started work and that there was an effective induction process. There was a process for handling complaints and comments, but no formal complaints had been received recently.