St Georges Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement with a breach of 1 legal regulation in relation to safe care and treatment. At this assessment the rating has changed to inadequate with a continued breach of legal regulation of safe care and treatment. We also found 1 new breach of legal regulation as the provider was not ensuring people were being supported by enough staff.

This meant people were not safe and were at risk of avoidable harm.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety when incidents and accidents occurred. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Incidents and accidents were not always being documented so they could be reviewed by the management of the service. For example, 1 person had a bruise to their arm and no incident form filled had been completed to support this. We raised this with the deputy manager who confirmed they would take action to review this and make a referral to the local safeguarding team. Following our inspection, they confirmed they had taken action to document the incident, and the incident had been raised with the local safeguarding team.

During our inspection, we raised an incident with the regional manager relating to 1 person. The regional manager took action to ensure the incident was documented, although no concerns had been raised with the local safeguarding team. This incident could have resulted in an unexplained injury. Both of these incidents were unexplained incidents and had resulted in either bruising or a possible injury. We raised this feedback with the registered manager and with the provider’s executive team. They confirmed following our inspection they had taken action to raise both these incidents as a safeguarding concern and review the person’s care plan and update as needed.

The provider’s regional manager undertook reviews of incidents and accidents. They collated this within a monthly report. This identified the type of incident, and if improvements were needed to the person’s care planning documentation. We were not always assured the provider’s quality assurance systems were identifying where incidents had occurred but were not being documented and that all actions including referrals were being made and outcomes documented as required.

The management team for the service held daily clinical meetings with nursing staff. This was an opportunity to discuss any changes to people’s needs, such as if they were unwell, any incidents and accidents and any safeguarding concerns. Documentation confirmed discussions were held with staff at these meetings.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety and make referrals to other professionals when required.

We were not always assured referrals were being made for people when they were needed. For example, when people were losing weight. We found 1 person had been losing weight for several months. However, we were informed during the inspection a referral to seek support for this person had only just been made. Other people had also lost weight. It was not clear what the service was doing to support people with their weight loss, except for making a referral as we observed and found no interim arrangements being made whilst awaiting this referral. Two professionals raised their concerns to us about how referrals were being made. One professional said, “We have had recent concerns within our team regarding the care home not being proactive and reaching out to the appropriate agencies when there are concerns.”

However, where people had been referred to health professionals, for example speech and language therapists, their care plans contained information about how to support them in line with professional guidance. The dementia wellbeing team were working with the service to improve dementia care. A professional said, “I find staff are receptive and willing to learn more about dementia. They will identify residents they would like reviewed.”

The service had systems to support people being admitted to the service safely. The registered manager and deputy manager completed preadmission assessments to assess whether they could meet people’s care needs before people moved into the service. When people moved in, they were provided with a guide which contained information about the home and what people could expect.

The provider was not always ensuring there was a system in place to identify and raise safeguarding concerns when required. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Although people and relatives knew the management of the service, we received mixed feedback from them when concerns had been raised as they were not always familiar with what actions had been taken to resolve the situation. For example, 1 relative raised with us where an incident had occurred. They confirmed some actions had been taken, although they were not aware if the situation had fully resolved for the person. Another relative raised an incident that had involved another resident. They were unaware of the outcome of this. We requested a response from the service, however this was not provided. This meant we were not assured actions were being taken to provide people with safe care.

The provider ensured staff had safeguarding training and staff were able to demonstrate a good understanding of the types of abuse and who to go to.

People’s care plans confirmed if the person had capacity. Not all people had a mental capacity assessment and best interest paperwork completed if they lacked capacity. For example, 1 person had no mental capacity assessment and best interest decision relating to their diabetes care and support. Another person needed a review of all aspects of their care and support following a decline in their health. Deprivation of Liberty Safeguards (DoLS) applications had been made to the local authority, and the service had a system in place to monitor those authorised and those still pending. Deprivation of Liberty Safeguards are part of the Mental Capacity Act 2005 (MCA) and people can only be deprived of their liberty with appropriate legal authority.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider at our last inspection was in breach of 1 legal regulation. This was because the provider was not ensuring people were receiving safe care and treatment.

At this inspection we found improvements were still needed to ensure people were receiving safe care and treatment.

For example, during our inspection we found improvements were needed to people’s care planning information and risk assessments. As care plans had no guidance in place to support staff with people’s moving and handling equipment and techniques. We also found people had no allocated sling and not all of these were not being safety checked as required. People who had specialist equipment such a pressure relieving mattresses did not always have their mattresses set to the appropriate setting. Their risk assessment and other supporting documentation contained no information on what their mattress should be set to and the checks undertaken had not identified people were at risk due to their mattress not being at the appropriate setting. Documentation we reviewed for 1 person confirmed on occasions they had not received repositioning every 2 hours as required. We found 2 people needed more information within their diabetes care plan on how staff were to support them with this, including their blood sugar ranges and equipment.

People, relatives and staff all raised with us about improvements needed to people’s care and support. For example, we received feedback that improvements were needed to people having their hair washed and providing support when required. People and relatives said care was not always provided quickly or when needed. They also said there was not always enough staff, and some people had lost items of clothing. During our inspection equipment arrived so people could be supported with their hair washing.

We raised our concerns with the management of the service and the provider’s executive team so they could review this feedback and take any actions necessary.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service did not have an effective system for checking all moving and handling equipment used by people to ensure it was regularly serviced and safe for use. Some people were supported to use equipment such as a hoist and sling. However, we found some slings had not had regular health and safety checks in line with legal requirements. They were not labelled to show who they belonged to. We fed this back to the management team. They took immediate action to address this. They provided us with an updated register which recorded up to date information about slings. We did not find any evidence anyone had come to harm.

The service was using communal bathrooms as storage areas for moving and handling equipment and laundry trolleys. This posed a risk to people who used the bathrooms independently or where staff supported people to use these bathrooms.

The provider had not assessed potential risks within the environment to ensure they had taken measures to reduce any identified risks. For example, no risk assessment was in place where people could access the stairs, garden or the communal lounge areas where a staff member was always required. We fed this back to the management team, who advised risk assessments would be completed.

The manager did not have a system to monitor staff attendance of fire drills, to ensure all staff were aware of how to safely evacuate people in the event of a fire. However, staff had completed fire awareness training.

The service had an up-to-date fire risk assessment, and each person had a Personal Emergency Evacuation Plan (PEEP), in case of emergency. However, some PEEPs did not contain enough information around how to support people to evacuate the home.

The provider had an environmental service improvement plan. They were completing some refurbishment work which included the redecoration of bedrooms and communal areas.

Checks and reviews of essential services including gas, electricity and water were completed regularly. A maintenance team completed environmental checks to monitor the safety of the premises and equipment.

The provider did not make sure there were enough skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

For example, we found people were not always supported with enough staff to ensure they received safe care and treatment. As we found people within the lounge area were not always being supported by a member of staff. The management of the service confirmed a member of staff should always be in the communal lounge areas. On 1 occasion we observed there were no staff in the first-floor lounge for 30 minutes. Within this time, 1 person who was at high risk of falls tried to mobilise themselves. This meant they were at risk of falling.

People and relatives told us there were not always enough staff to support people with their care. People were observed in the same clothes during the inspection and staff confirmed they were not always able to support people with their personal care and incontinence needs when people needed this. People and relatives raised with us they had to wait for call bells to be answered and for staff to support them. On occasions they told us this could take up to half an hour. During the inspection, some people were not supported with their personal care until lunch time. The registered manager confirmed the service had about 160 vacant care staff hours and they were using agency staff as an interim whilst they undertook recruitment in the service.

People and relatives told us staff were polite and kind. However, they felt staff were not always familiar with people’s individual needs or there being enough staff to adequately provide people with support when they needed this. For example, 1 person told us, “They are short of staff, they don’t have enough.” Relatives also felt more staff was needed. One relative told us, “I think they need more staff.” Another relative told us, “They are very busy. Often it takes up to 30 minutes for a carer to respond.” Relatives also raised with us mixed feedback about staff being familiar with people’s individual needs. For example, 1 relative told us, “The day staff know (Name of person) although the night staff just do what is needed. There is very little interaction from them.” One health and social care professional provided their feedback on how they found the staffing at the service. They told us, “There has always appeared to be a high staff turnover, reliance on agency staff and therefore a lack of knowledge or familiarity with the residents and their needs.”

Staff also raised with us they were not always able to meet people’s individual needs due to there not always being adequate staff to support people. We raised this feedback with the management of the service following our inspection so they could review if people were being adequately supported as needed.

The registered manager and deputy had started to support staff through formal supervisions and meetings. Staff we spoke with had mixed feedback about the support provided to them. The provider had sought staff feedback. This had identified improvements were needed within the service and the provider had an action plan on how they were going to address this.

Staff were not always provided relevant training for the role. For example, although staff had received mandatory training in moving and handling, safeguarding adults and mental capacity. We found care staff had not been provided with diabetes training and re-fresher training where they were applying topical creams to people. The registered manager confirmed they were supporting staff with additional training in dementia care, and this was being provided by the dementia care service who were visiting. The provider reviewed what training agency staff had received and these staff completed an induction to the service. Documentation confirmed nursing staff had completed medicines competency reviews. Following our inspection, we were sent the provider’s training policy. This contained no information such as what mandatory training staff required for their role or how often they should receive certain training.

The provider ensured staff went through a safe recruitment process. This included their right to work in the UK and their fitness for the role. All staff had undergone a Disclosure and Barring Service (DBS) check before starting their role, had identification checks in place and references completed to ensure they were suitable to work with vulnerable people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, during our inspection we identified staff were not always following best practice guidance on using personal protective equipment.

For example, we observed 2 staff not wearing their surgical mask in line with government guidance. This could pose an infection control risk to people and staff. We raised this with the management of the service.

Staff had completed infection prevention and control training and personal protective equipment, (PPE) was available to staff throughout the service.

People were supported with vaccinations, and this was documented within people’s care planning information. The service was observed to be clean. This included dining room tables and lounge chairs. Although improvements where needed to dirty laundry as we found this was being stored in communal bathrooms on occasions. We raised these shortfalls with the registered manager so they could review this.

The provider was not always ensuring the management of medicines was safe. We found improvements were needed to ensure medicines stock was accurate, medicines were available and guidance was up to date where people needed analgesia. Risk assessments were also needed for medicines that posed a flammable risk.

People received their medicines from nursing staff. Care staff were responsible for administering topical creams. Medicines were stored securely and staff monitored temperatures where medicines were stored. There was clear guidance in place for staff to follow when they needed to administer ‘as required’ medicines. However, there was not enough guidance and information on when people might need analgesia or if staff had checked people’s pain-relieving patches in between this being changed. Improvements were also needed to ensure medicines stock was accurate and that medicines were being reviewed and disposed of when required. No risk assessments were in place for topical creams that posed a flammable risk.Two people could benefit from having a review from a diabetes practitioner for the use of oral glucose gel should they need this for their diabetes care. We shared this feedback with the registered manager and deputy so they could take any actions required.

The provider’s medicines audits had not identified these shortfalls found during our inspection.