• Care Home
  • Care home

Archived: St Nicholas Care Home

Overall: Requires improvement read more about inspection ratings

21 St Nicholas Drive, Netherton, Liverpool, Merseyside, L30 2RG (0151) 931 2700

Provided and run by:
Bupa Care Homes (CFHCare) Limited

Important: The provider of this service changed. See new profile

All Inspections

1 March 2017

During a routine inspection

St Nicholas Nursing Home is owned and operated by BUPA, a large national organisation. The home provides nursing and personal care for up to 176 people in six separate units. Three units provide general nursing care; one provides nursing care for people living with dementia. One unit provides personal care to people with dementia and one provides nursing care to people who have a learning disability. The home is set within a residential area and is close to all amenities and public transport.

There were 75 people accommodated at the time of the inspection.

This was an unannounced inspection which took place over two days. The inspection team consisted of two adult social care inspectors, a pharmacy inspector and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

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

We last inspected the home in August 2016 and, although improved in some areas, we found continuation of serious breaches of regulations. The home was rated as ‘inadequate’ overall; the home had been placed in special measures following an inspection in February 2016 and we continued with this measure. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate

care and work with, or signpost to, other organisations in the system to ensure improvements are made.

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

We had already taken enforcement action from a previous inspection as we had issued a notice to stop any further admissions to the home. The statutory notice we issued remained in place at this inspection.

At this inspection we found improvements in all areas and all previous breaches of regulations had been met. Because of the improvements the overall quality rating has been raised to ‘requires improvement’ and the home has been removed from special measures.

At our last inspection in August 2016 we had found the home in breach of regulations relating to safe administration of medicines because people were not always protected by the medication administration systems in place. At this inspection we found people protected against the risks associated with medicines because the provider’s arrangements to manage medicines were now consistently followed. The breach had been met.

Previously we had found some people were not assessed for any risks regarding their health care needs. The risk of not updating changes to people’s care plans is that staff might be unaware of their changed care needs and care might not be effectively monitored and reviewed exposing people to unnecessary risk. We now found more consistency regarding this and clinical risks such as, pain assessment and management, assessing risks around people with diabetes, people assessed as risk of falls, and risk of inadequate nutrition were now being consistently monitored. The breach had been met.

We had previously found staff needed to be more aware of the first aid procedures and equipment used in case of an accident or emergency; first aid equipment had also not been checked and maintained. This had been attended to and the breach was now met.

We had previously found that the home was not fully operating in accordance with the principles of the Mental Capacity Act 2005 (MCA). Although there were examples indicating good practice we found some hesitancy and misunderstanding in particular around the use of the ‘two stage mental capacity assessment’ and when this should be used as part of making ‘best interest’ decisions for people. On this inspection we found improvements had been made. Staff evidenced a better understanding of the principals involved, including an understanding of the need to assess individual decisions relating to care and treatment.

On the previous inspection we found the systems in place to monitor on-going standards in the home had not been effective. On this inspection the provider had continued to developed systems to monitor the quality of care in the home; these had helped to improve consistency in areas of clinical care management, such as medication safety.

We saw references in care files to individual ways that people communicated and made their needs known. We also saw good examples where people had been included in the care planning so they could play an active role in their care although there was recognition that this could be further improved.

Previously we had made comments regarding the accessibility and user friendliness of the care records and care documentation in use. We found care records had improved and were easier to follow and to access necessary information.

Staff told us the training they received was good. We saw that there had been recent training / update around the principles of the MCA following recommendations from the last CQC inspection. The ‘training matrix’ we saw showed that staff were updated regularly in key areas of care and there was an established induction programme for staff.

We observed there was enough staff to carry out care in a timely manner. We saw staff were attentive to the needs of people and no one appeared to be in distress through lack of attention.

Staff files showed appropriate recruitment checks had been made so that staff employed were ‘fit’ to work with vulnerable people.

People we spoke with and their relatives told us they felt safe in the home. People knew who to speak with if they felt concerned about anything. We made observations on all units including those specialising in people with dementia and learning disability. We saw that people who could not express their thoughts and feelings vocally were settled and supported. Staff were observed to be attentive to people’s care needs as they arose. Nobody we spoke with or observed expressed any issues regarding their safety.

There have been a number of safeguarding investigations at St Nicholas Nursing Home since our last inspection; these had reduced in number from previous inspections. The home had assisted the local authority safeguarding team and agreed protocols had been followed in terms of investigating. This helped ensure any lessons could be learnt.

We found that the home was clean and hygienic.

We observed meal times and saw that meals were served appropriately and the portion size was also appropriate. We saw that people who needed support to eat had sufficient staff time allocated and that staff took time to talk with and socialise with people.

People we spoke with and their relatives said that they (or their relatives) were being treated with respect, dignity and kindness.

A complaints procedure was in place and people, including relatives, we spoke with were aware of this procedure. We spoke with the manager who showed us how complaints were recorded and responded to.

We saw that people were provided with a range of social activities and these continued to be developed with particular reference to providing activity for people with dementia.

30 August 2016

During a routine inspection

St Nicholas Nursing Home is owned and operated by BUPA, a large national organisation. The home provides nursing and personal care for up to 176 people in six separate units. Three units provide general nursing care; one provides nursing care for people living with dementia. One unit provides personal care to people with dementia and one provides nursing care to people who have a learning disability. The home is set within a residential area and is close to all amenities and public transport.

There were 87 people accommodated at the time of the inspection.

This was an unannounced inspection which took place over three days. The inspection team consisted of two adult social care inspectors, two pharmacy inspectors, a nurse specialist advisor in wound care and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The service had 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.

We last inspected the home in February 2016 and found serious breaches of regulations. The home was rated as ‘inadequate’ overall. We placed the service in special measures. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate

care and work with, or signpost to, other organisations in the system to ensure improvements are made.

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

We had already taken enforcement action from our previous inspection in July 2015. We had issued a notice to stop any further admissions to the home. The statutory notice we issued remained in place at this inspection.

At our last inspection in February 2016 we had found the home in breach of regulations relating to safe administration of medicines. This was because people were not always protected by the medication administration systems in place. At this inspection we found people were still not protected against the risks associated with medicines because the provider’s arrangements to manage medicines were not consistently followed.

We found most people were assessed for any risks regarding their health care needs. This was not however consistent across all units and we found that some clinical risks such as, pain assessment and management, assessing risks around people with diabetes, people assessed as risk of falls, and risk of inadequate nutrition were not being consistently monitored. The risk of not updating changes to peoples care plans is that staff might be unaware of their changed care needs. There is therefore an increased risk that specific areas of care might not be effectively monitored and reviewed exposing people to unnecessary risk.

We found staff needed to be more aware of the first aid procedures and equipment used in case of an accident or emergency.

We found that the home was not fully operating in accordance with the principles of the Mental Capacity Act 2005 (MCA). Although there were examples indicating good practice we found some hesitancy and misunderstanding in particular around the use of the ‘two stage mental capacity assessment’ and when this should be used as part of making ‘best interest’ decisions for people.

On the previous inspection we found the systems in place to monitor on-going standards in the home had not been effective. On this inspection we found the service had many well developed systems in place to monitor the quality of care in the home. However, there were still areas of clinical care management, such as medication safety, that remained in need of improvement and had not been monitored effectively by existing audits and systems in the home.

The concerns we identified are being followed up and we will report on any action when it is completed.

We saw references in care files to individual ways that people communicated and made their needs known. We also saw examples were people had been included in the care planning so they could play an active role in their care although this was not consistent across all units.

We made a recommendation in the report.

We saw that an underlying component to some of the continued failings was the accessibility and user friendliness of the care records and documentation in use. We found care records extremely bulky and difficult to negotiate and to find information.

At the last inspection we identified shortfalls in care for people who had specific clinical care needs around wound care. We found that assessments and care planning for some of these people had not been updated and implemented to ensure care was safe and reflected people’s changing needs. We found this area of care had improved and wound care and people whose skin integrity was at risk were being monitored well.

Previously we had found that there was a lack of support for nursing staff to fully develop their skills and knowledge to effectively manage some aspects of clinical care. This had also improved with clinical staff having undergone training and supportive supervision to assist them in their clinical work.

We observed there was enough staff to carry out care in a timely manner. We saw staff were attentive to the needs of people and no one appeared to be in distress through lack of attention.

Staff files showed appropriate recruitment checks had been made so that staff employed were ‘fit’ to work with vulnerable people.

People we spoke with and their relatives told us they felt safe in the home. People knew who to speak with if they felt concerned about anything. We made observations on all units including those specialising in people with dementia and learning disability. We saw that people who could not express their thoughts and feelings vocally were settled and supported. Staff were observed to be attentive to people’s care needs as they arose. Nobody we spoke with or observed expressed any issues regarding their safety.

There have been a number of safeguarding investigations at St Nicholas Nursing Home since our last inspection. The home had assisted the local authority safeguarding team and agreed protocols had been followed in terms of investigating. This helped ensure any lessons could be learnt.

We found that the home was clean and hygienic.

We observed meal times and saw that meals were served appropriately and the portion size was also appropriate. We saw that people who needed support to eat had sufficient staff time allocated and that staff took time to talk to and socialise with people.

People we spoke with and their relatives said that they (or their relatives) were being treated with respect, dignity and kindness.

A complaints procedure was in place and most people, including relatives, we spoke with were aware of this procedure. We spoke with the registered manager who showed us how complaints were recorded and responded to.

We saw that people were provided with t range of social activities and these continued to be developed.

The rating for the key question ‘Is the service safe?’ is ‘inadequate’ for the fourth consecutive inspection. This means that the service remains in ‘Special measures’ by CQC.

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

17 February 2016

During a routine inspection

St Nicholas Nursing Home is owned and operated by BUPA, a large national organisation. The home provides nursing and personal care for up to 176 people in six separate units. Three units provide general nursing care; one provides nursing care for people living with dementia. One unit provides personal care to people with dementia and one provides nursing care to people who have a learning disability. The home is set within a residential area and is close to all amenities and public transport.

This was an unannounced inspection which took place over three days on 17, 18 and 19 February 2016. The inspection team consisted of two adult social care inspectors, two pharmacy inspectors, a nurse specialist advisor and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The service had 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.

We last inspected the home in July 2015 and found serious breaches of regulations. The home was rated as ‘requires improvement’ overall and was rated ‘inadequate’ when we asked the question ‘is the service safe?’ Following the inspection we issued a notice to stop any further admissions to the home. The statutory notice we issued remains in place at this inspection.

At our last inspection in July 2015 we had found the home in breach of regulations relating to safe administration of medicines. This was because people were not always protected by the medication administration systems in place. At this inspection we found people were still not protected against the risks associated with medicines because the provider’s arrangements to manage medicines were not consistently followed.

At the last inspection we found the home to be in breach of regulations regarding assessment and review of peoples care plans to help ensure responsive care delivery as people’s needs changed. We looked in detail at the care received by 12 of the people living at St Nicholas Nursing Home. We found examples of good care and good practice and saw the service had developed better care planning systems and reviews. However we identified shortfalls in care for people who had specific clinical care needs such as wound care, pain relief and the management and care of people who were being fed and given medication via a tube into their stomach [PEG feeding]. We found that assessments and care planning for some of these people had not been updated and implemented to ensure care was safe and reflected peoples changing needs. The risk of not updating major changes to peoples care plans is that new staff might be unaware of their changed care needs and there is an increased risk that specific areas of care might not be effectively monitored and reviewed exposing people to unnecessary risk.

We found that there was a lack of support for nursing staff to fully develop their skills and knowledge to effectively manage these aspects of clinical care.

We found the service had many well developed systems in place to monitor the quality of care in the home. However, there were areas of clinical care management that still needed to be improved and these had not been identified by existing audits and systems in the home.

The concerns we identified are being followed up and we will report on any action when it is complete.

At our last inspection in September 2014 we had found the home in breach of regulations relating to staffing. At that time, levels of nursing and care staff were not sufficient to ensure people received a consistent level of safe care. We told the provider to take action. At this inspection we found that overall staffing had been improved. We observed there was enough staff to carry out care in a timely manner. We saw staff were attentive to the needs of people and no one appeared to be in distress through lack of attention.

Staff files showed appropriate recruitment checks had been made so that staff employed were ‘fit’ to work with vulnerable people.

People we spoke with and their relatives told us they felt safe in the home. People knew who to speak with if they felt concerned about anything. We made observations on all units including those specialising in people with dementia. We saw that people who could not express their thoughts and feelings vocally were settled and supported. Staff were observed to be attentive to people’s care needs as they arose. Nobody we spoke with or observed expressed any issues regarding their safety.

There have been a number of safeguarding investigations at St Nicholas Nursing Home since our last inspection. The home had assisted the local authority safeguarding team and agreed protocols had been followed in terms of investigating. This helped ensure any lessons could be learnt.

We found people were assessed for any risks regarding their health care needs. Risk assessments had been carried out to assess people’s risk of developing a pressure sore for example. We saw some assessments for the use of bedrails to help ensure people were safe. One person displayed some challenging behaviours that staff were closely monitoring and reviewing with health professionals.

We found that the home was clean and hygienic. We reported to the managers some observations for further improvements.

We found that the home was operating in accordance with the principles of the Mental Capacity Act 2005 (MCA). Although care practices were consistent and this indicated staff were generally following good practice we found some hesitancy around fully understanding the use of the ‘two stage mental capacity assessment’ and when this should be used.

We made a recommendation in the report regarding this.

We observed meal times and saw that meals were served appropriately and the portion size was also appropriate. We saw that people who needed support to eat had sufficient staff time allocated and that staff took time to talk to and socialise with people.

People we spoke with and their relatives said that they (or their relatives) were being treated with respect, dignity and kindness. Dignity champions were appointed on the units to oversee these standards and implement ‘best practice’.

We saw references in care files to individual ways that people communicated and made their needs known. We also saw examples were people had been included in the care planning so they could play an active role in their care although this was not consistent and generally centred around specific assessments or ‘best interest’ decisions.

A complaints procedure was in place and most people, including relatives, we spoke with were aware of this procedure. We spoke with the registered manager who showed us how complaints were recorded and responded to.

Special measures.

The rating for this service is ‘inadequate’. This means that the service has been placed into ‘special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

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

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

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

is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

15 & 16 July 2015

During an inspection looking at part of the service

This was an unannounced inspection which took place over two days on 15 & 16 July 2015. The inspection was ‘focused’ in that we were following up on previous breaches of regulations identified on an inspection in January 2015; these were in the areas of – medication management, infection control, care planning and privacy and dignity. We also included a review of staffing as we had received some concerns prior to the inspection indicating staffing inconsistencies effecting care.

This report only covers our findings in relation to these specific areas / breaches of regulations. They cover three of the domains we normally inspect; 'Safe', ‘Caring’, and ‘Responsive’. The domains ‘Effective’ and ‘Well-led’ were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘St Nicholas Nursing Home' on our website at www.cqc.org.uk.

St Nicholas Nursing Home is owned and operated by BUPA, a large national organisation. The home provides nursing and personal care for up to 176 people in six separate units. Three units provide general nursing care; one provides nursing care for people living with dementia. One unit provides personal care to people with dementia and one provides nursing care to people who have a learning disability. The home is set within a residential area and is close to all amenities and public transport.

The service had 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.

Medicines

At our last inspection in January 2015 we found the home in breach of regulations relating to safe administration of medicines. This was because people were not always protected by the medication administration systems in place. We told the provider to take action. The provider’s action plan told us that systems had been reviewed and improved. At this inspection we found that the management of medicines were still not safe. From our findings during the visit and the continued high incidence of medicine errors, we found that people were still not protected against the risks associated with medicines. We found medicines were not being given at the right times, inappropriate storage, people missing medicines as they had not been ordered, medicines given ‘when required’ lacked supporting protocols, gaps and were seen in medication administration records.

Staffing

In the four weeks prior to our inspection we received three separate concerns regarding the staffing levels in the home. Two of the concerns related to the provision of consistent nursing staff on the units and was causing concern with some aspects of care. For example, completion of medication rounds was difficult and meant that people were not being given medication at the right time.

We visited five of the six units in the home and checked on staffing levels. We were told by staff that not units were consistent in maintaining staffing levels and there were shortages on occasions. On the nursing units we found delays in completing the medicine rounds when one nurse was allocated. We were told medication rounds were particularly difficult to time right when the unit was reduced to three care staff which had happened occasionally. On these occasions the nurse also needed to support care staff delivering personal care and this meant difficulties with monitoring people who needed nursing care needs. We found that people had not been given some of the medicines at appropriate times.

We spoke with the registered manager regarding these concerns. We were told that there was an ongoing issue with the provision of nursing staff to the home and there was a high usage of agency staff to cover. The manager felt this was improving and there was a sustained plan to recruit nursing staff.

Although improving, the overall evidence at the time of our inspection was that there was insufficient numbers of suitably qualified and experienced staff to meet the needs of the people using the service and other regulatory requirements at all times especially medication safety.

Care planning

At our last inspection in January 2015 we found the care planning for some people had not been updated to reflect their changing care needs. The risk of not updating major changes to people’s care plans is that staff may be unaware of their changed care needs and there is an increased risk that specific areas of care might not be effectively monitored and reviewed. We told the provider to take action.

Following the last inspection we received an action plan from the provider that told us how improvements would be made. Part of this included a full review of the care plan documentation and a move towards a new system of assessment and care planning to focus the care with a more personalised way.

We reviewed people’s care records on three of the units we visited. Most of the care records we reviewed had changed over to the new care planning system and so had had a recent review and the care plan had been updated and therefore reflected their current care needs. We found these care plans to be more focused in terms of identifying and personalising peoples care needs.

We found, however, some examples were staff had not still updated care plans and records effectively as care needs had changed.

For example the care plans for two people contained a range of care planning information. However, the care plans had been written when both people were far more able and independent. The care plans included a monthly evaluation and these contained more up to date brief information to reflect the change in the person’s needs. This showed that the original information in people’s care plans was out of date. Staff were therefore not reviewing/evaluating the correct information. For example the care plans read that one person could ‘weight bear’ [in terms of their mobility] and use a stand aid hoist and use the toilet when this was no longer the case and they now needed to be hoisted for all transfers and were incontinent.

The risk of people’s care being missed was increased without a clear plan of care which is regularly updated.

The concerns we identified are being followed up and we will report on any action when it is complete.

At our last inspection in January 2015 we had found the home in breach of regulations relating to cleanliness and infection control. This was because people were not protected from the risk of infection because appropriate guidance was not being followed. People were not being cared for in a clean, hygienic environment. We told the provider to take action. At this inspection we found that overall management of infection control had progressed and, overall, regulations were now being met.

At our last inspection we found an example where privacy when using the toilet [for people living with dementia] had been infringed. On one unit we found a lack of effective locks on toilet/bathroom doors for people to use. This was seen to compromise people’s privacy and dignity. We told the provider to take action.

The provider sent us their action plan which told us locks had been provided on toilets and this would continue to be monitored with regular maintenance checks. On our inspection we checked a sample of locks on bathroom and toilet doors and these were in place and working.

We spoke with people who lived at the home about privacy and dignity and no concerns were raised. Warm, friendly interactions between people who lived at the home and staff were seen throughout the inspection. We made observations of staff carrying out care that showed a relaxed and homely atmosphere.

28-30 January 2015

During a routine inspection

St Nicholas Nursing Home is owned and operated by BUPA, a large national organisation. The home provides nursing and personal care for up to 176 people in six separate units. Three units provide general nursing care; one provides nursing care for people living with dementia. One unit provides personal care to people with dementia and one provides nursing care to people who have a learning disability. The home is set within a residential area and is close to all amenities and public transport.

This was an unannounced inspection which took place over three days on 28, 29 and 30 January 2015. The inspection team consisted of three adult social care inspectors, a pharmacy inspector, a specialist advisor for infection control and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

The service had 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.

We asked people whether they felt safe in the home. We were told, “We are looked after very well – I am moving soon but I have felt very safe here’’ and “All the staff are very good here – if I had a problem I could talk to any one of them.’’ One visitor described their relative as appearing to be “settled and safe” since their admission to the home.

We made observations on all units [houses] including those specialising in people with dementia. We saw that people who could not express their thoughts and feelings vocally were settled and supported. Staff were observed to be attentive to people’s care needs as they arose. Nobody we spoke with or observed expressed any issues regarding their safety.

There have been a number of safeguarding investigations at St Nicholas Nursing Home since our last inspection. The home had assisted the local authority safeguarding team and agreed protocols had been followed in terms of investigating and ensuring any lessons had been learnt and effective action taken. Two of the investigations by social services evidenced failings in care at the home.

At our last inspection in September 2014 we had found the home in breach of regulations relating to staffing. At that time, levels of nursing and care staff, were not sufficient to ensure people received a consistent level of safe care. We told the provider to take action. At this inspection we found that overall staffing had been improved.

Staff we spoke with told us there had, overall, been a marked improvement in the level and consistency of staffing. One staff said, ‘’Things have improved. Staff numbers have been quite stable recently. This gives us more time to organise care.’’ When we looked at the duty rotas for each unit we saw that the providers designated numbers of staff were being met.

We observed there were enough staff to carry out care in a timely manner. We saw staff were attentive to the needs of people and no one appeared to be in distress through lack of attention.

Staff files showed appropriate recruitment checks had been made so that staff employed were ‘fit’ to work with vulnerable people.

The registered manager told us staff recruitment would continue with the aim of further stabilising each house and this would help ensure house managers had necessary time to develop their role and carry out their management duties.

We found on inspection that people were assessed for any risks regarding their health care needs. Risk assessments had been carried out to assess people’s risk of developing a pressure sore for example. We saw some assessments for the use of bedrails to help ensure people were safe. We reviewed the care of one person on the house accommodating people with a learning disability. The person displayed some challenging behaviours that staff were closely monitoring. Within the person’s care plan we saw a comprehensive action plan to monitor behaviour including the use of distraction techniques. This helped the person to be as independent as possible.

At our last inspection in September 2014 we had found the home in breach of regulations relating to safe administration of medicines. This was because people were not always protected by the medication administration systems in place. We issued a warning notice and told the provider to take action. The provider’s action plan told us that systems had been reviewed and improved.

At this inspection we found that overall management of medicines had improved, however, from our findings during the visit and the incidence of medicine errors, we found that overall people were still not fully protected against the risks associated with medicines because the provider’s arrangements to manage medicines were not consistently followed.

We have told the provider to take further action.

At our last inspection in September 2014 we had found the home in breach of regulations relating to cleanliness and infection control. This was because people were not protected from the risk of infection because appropriate guidance was not being followed. People were not being cared for in a clean, hygienic environment. We told the provider to take action. At this inspection we found that overall management of infection control had progressed but there were still areas that needed improvement.

On general inspection of units [houses] we found levels of cleanliness to have improved. Toilets and bathrooms had hand wash facilities including liquid soap and paper towels for use. There was better organisation and checking by managers to ensure standards were improving. We found staff had attended training and where more knowledgeable regarding infection control.

There were still however, some areas of concern and inconsistency. For example, not all staff were seen to be adhering to hand washing routines. Some cleaning was not thorough in the dining areas and some bedrooms. There was a commode pan stored in the sluice still contaminated. This was lifted from the shelf it was stored, which was also very dusty. The clinical room on one house had an old air-conditioning unit that did not work this had been there several months and was cluttering the room; it was also very dusty underneath. Overall we found there had been enough progress but there still needed to be further development of staff roles and on-going vigilance.

We have told the provider to take action

We looked in detail at the care received by 13 of the people living St Nicholas Nursing Home. One person, who lived with dementia, had highly dependent and complex care needs. We saw that they had received input from a range of social and health care professionals who had linked in effectively with the home. One health care professional told us the manager and staff had been very proactive in managing the person’s care. Professional support had been documented by the Community Mental health team [CMHT]. There were also some records to show input from the person’s GP and dietician.

We reviewed the care of people who were experiencing pain, or had ongoing health conditions that required constant monitoring. We found that referrals had been made to provide appropriate health care input from external professionals when needed.

We looked at the training and support in place for staff. The training manager told us about the induction programme for new staff. New staff we spoke with said they had attended and felt the induction prepared them for their role. The training manager showed us a copy of the staff training matrix which identified and plotted training for staff in ‘statutory’ subjects such as health and safety, medication, safeguarding, infection control and fire awareness. Staff spoken with said they felt supported by the training provided.

We were told about plans to develop staff education in dementia awareness. There was training to develop ‘person centred coaches’ who would lead in dementia care. Currently there were two staff trained. The home had also identified clinical leads in infection control and there were identified ‘dignity’ champions. We found that these developments were very new and needed to be embedded; for example training in dementia care. The home had identified areas for improvement in best practice for dementia care but these had yet to be fully introduced.

We looked to see if the service was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. People living at St Nicholas’ varied in their capacity to make decisions regarding their care. We saw examples where people had been supported and included to make key decisions regarding their care. Where people had lacked capacity to make decisions we saw that decisions had been made in their ‘best interest’. We saw this followed good practice in line with the MCA Code of Practice.

We also discussed some of the decisions regarding the right to refuse specific medical treatment in case of a cardiac arrest [‘do not resuscitate’ (DNR) procedures]. These did not always include clear evidence of a mental capacity assessment for people lacking the capacity to make a decision. In some cases we could not see whether the person’s family had been consulted as part of the best interest decision. We discussed how some DNR decisions could be better evidenced and recorded.

We found the home supported people who were on a deprivation of liberty authorisation [DoLS]. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

We observed the dinner time meal on some of the houses and saw that meals were served appropriately and the portion size was also appropriate. We saw that people who needed support to eat had sufficient staff time allocated and that staff took time to talk to and socialise with people. There were staff on hand for people who required support with meals. Some menus were not clearly displayed. We discussed this with the manager who said they would look at improving the way the menus were displayed especially on the dementia care houses.

People we spoke with and their relatives said that they (or their relatives) were being treated with respect, dignity and kindness. One relative described staff as, “friendly and helpful.’’ They also said when their relative was being moved using a hoist, “Staff talk to [person] before they lift [them] and talk [person] through it.”

We observed staff in the communal areas of all the houses we visited. Staff interactions towards people were respectful and pleasant. During these interactions, staff appeared to listen carefully to and made efforts to communicate with people effectively.

We asked whether privacy was respected. One relative commented, “I have seen staff knocking on doors before going into a person`s room - they are very thoughtful.” This was not always consistent. We found an example where privacy when using the toilet [for people living with dementia] had been infringed. On one unit we found a lack of effective locks on toilet/bathroom doors for people to use. One toilet had no lock on at all. This was seen to compromise people’s privacy during our inspection.

We told the provider to take action.

We saw different levels of staff social interaction on different houses. If there was a high ratio of very dependent people in terms of personal care [for example the dementia nursing house] this time was reduced. The home employed ‘hobby therapists’ who were responsible for initiating some activities within the home and we saw some interactions at various times which were positive and helped people to have a greater sense of wellbeing.

We saw references in care files to individual ways that people communicated and made their needs known. We also saw examples were people had been included in the care planning so they could play an active role in their care although this was not consistent and generally centred around specific assessments or ‘best interest’ decisions. People and relatives told us they were not included in any of the reviews of care planning and we saw no evidence in care files. People and relatives told us, ‘Staff will always tell us if we need to know anything, such as a fall.’’

We looked at the care record files for 13 people who lived at the home. We found, some examples were staff had not updated care plans and records as care needs had changed. One example was a person who had returned from hospital three days previously with new care needs. The risk of not updating major changes to peoples care plans is that new staff might be unaware of their changed care needs and there is an increased risk that specific areas of care might not be effectively monitored and reviewed.

We found examples where care planning had not been individualised with people’s individual communication needs; for example, a person who had experienced a stroke and a person who had a learning disability. We saw there had been no assessment of the use of any communication aids such as written communication sheets or pictures.

We told the provider to take action

We looked at the daily social activities that people engaged in. We asked people who lived at the home how they spent their day. We found variations between houses as to the level of daily activities for people. People’s comments varied but included, “There is nothing else to do” (but watch television), “Nothing goes on”, “There is not much entertainment.” We saw a good level of activity on a dementia care unit where people were engaged and active. This was not duplicated however in other houses that varied in their level of personalised activities.

A complaints procedure was in place and most people, including relatives, we spoke with were aware of this procedure. We spoke with the registered manager who showed us how complaints were recorded and responded to. We saw recent examples of complaints that had been investigated and a response made.

At our last inspection in September 2014 we had found the home in breach of regulations relating to assessing and monitoring the quality of service provision. This was because management did not always protect against unsafe care and treatment by identifying, assessing and monitoring through effective operating systems. We told the provider to take action.

Unlike our previous inspection the registered manager had now got two clinical services managers [CSM] in post to support the daily management systems in the home. The company had also provided another manager to work alongside the registered manager to provide any extra support needed. We spoke with these managers as well as other senior managers for BUPA. Managers felt they had openly acknowledged previous failings in the home and had developed action plans to improve standards and meet requirements.

The registered manager explained the organisation’s system of audits from ‘house’ level to senior management level and how the results of audits were monitored and fed through to higher managers in the company. Any areas for improvement could be picked up and an action plan devised to help ensure continual improvements. The area manager and quality assurance manager conducted some audits with the registered manager.

Overall we found the management systems in the home were ‘tighter’ and had assisted in the progress the home had made. There was still a need to evidence on-going consistency however.

Some issues we identified on inspection had not been identified by the homes own audits. We discussed some findings where certain auditing processes had not been ‘joined up’. In other words they had not provided effective feedback in good time so that improvement could be actioned. One example was the audit by the specialist dementia nurse into the dementia care environment on two of the houses, which had been undertaken some time ago but not fed back to the respective areas. Another was the annual resident and relative feedback survey. We saw the results of a survey dated January 2014 but this contained the results of a survey carried out in October 2013. The information about people’s feedback was poorly presented and was not user friendly for people reading it. The registered manager could not locate any actions that had been taken regarding any of the feedback. The registered manager said they would look at making this system better presented and timelier.

30 September and 1 October 2014

During an inspection looking at part of the service

Our inspection was carried out unannounced. We followed up on two areas that the home needed to make improvements in following our last inspection in May 2014. We also looked at two others areas were we had received recent concerns. The inspection helped answer three of the five questions we ask:

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We followed up on a previous inspection in May 2014 where there had been a breach of the regulations regarding the safe administration of medicines. We had made a requirement and told the provider to take action.

On this inspection we found that the service was still not safe with respect to medication administration. This was because people were not protected against the risks associated with medicines because the provider's arrangements to manage medicines were not consistently followed staff did not always have the information and skills needed to administer medication safely.

This is being followed up and we will report on any action when it is complete.

Prior to our inspection we had some concerns from Public Health England [PHE] about the practices around control of infection at St Nicholas'. A recent infectious outbreak involved three of the units in the home. There were concerns about the frequency and duration of the outbreaks. An audit carried out by PHE on two units at the home highlighted failings in the management of infection control.

At the time of our visit we looked at the systems in place to assess the risk of and to help prevent, detect and control the spread of infection. We found there were concerns with standards of environmental cleanliness and staff practices which could put people at risk.

This is being followed up and we will report on any action when it is complete.

Prior to our inspection we received a number of concerns about the staffing of the home. Concerns raised included lack of support for staff when there were shortages. It was reported that staff sickness was very high and staff morale was low.

On our inspection we checked whether sufficient numbers of appropriately qualified staff were in place to support people living at the home. We found that staffing levels were below what the provider had set to ensure a safe, consistent standard of care for people living at St Nicholas Nursing Home.

This is being followed up and we will report on any action when it is complete.

Is the service effective?

On our previous inspection in May 2014 we found inconsistencies in the arrangements in place for obtaining the consent of people in relation to their care and support. We made a requirement and told the provider to take action.

On this inspection we found improvements. We found that people were more included in their planned care and where people could not consent there were arrangements to ensure decisions were taken in the persons best interests. These arrangements were being applied more consistently.

The home had policies and procedures in relation to the Mental Capacity Act [2005] and Deprivation of Liberty Safeguards. We were told about current authorisations that had been made to ensure the home was acting within the law. This showed that the service understood the processes involved.

Is the service well led?

During our inspection we found evidence that the provider had failed to protect people living at St Nicholas Nursing Home against the risks of inappropriate or unsafe care and treatment. The management systems in place to enable the provider to assess and manage risk had not been effective.

7, 8 May 2014

During a routine inspection

Our inspection was carried out unannounced. As part of the outcomes we looked at, we followed up on three areas that the home needed to make improvements in following our last inspection in January 2014. The inspection helped answer our five questions:

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they were treated with respect and dignity by the staff. They told us care was good and if they had any medical issues that needed monitoring, or to be followed up, this was arranged. People told us they felt safe and well cared for.

We found that the service was not safe with respect to one aspect of medication administration. This was because people were not protected against the risks associated with use and management of creams, and other medicines for external use.

Systems were in place to make sure that managers and staff learn from events, such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduces the risks to people and helps the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. We were told about one application that had been made. This showed that the service understood the process involved. The home had also introduced a tool for measuring people's mental capacity in terms of individual decisions that might need to be made. When we spoke with staff they were unaware of how to make best use of this tool and under which circumstances it would be used. We spoke with the manager about the development of staff knowledge in the field of dealing with people who lacked capacity to make decisions, and particularly knowledge and awareness regarding the Mental Capacity Act and Deprivation of Liberty [DoLS]. We have asked the provider to review this and take action.

Is the service effective?

People's health and care needs were assessed. Specialist dietary, mobility and equipment needs had been identified in care plans where required. From reviewing the care of people we saw that the care plans reflected their current needs.

People told us that staff asked them about their care and they felt involved. This was not always reflected in the care documentation. Although some assessments indicated people had been involved in decision making, this was limited. None of the care plans we saw reflected any involvement by people recieving care. We have asked the provider to review this and take action.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, 'The staff are very kind and helpful. I was very ill when I first arrived and I'm a lot better now. I've put on weight and feel really good.' ' The staff are quick at getting the doctor if I need one.' 'We do different sorts of activities. It's very good. We get to choose whether we join in.' 'Staff are approachable and they work very hard.' 'Everybody is very helpful.' 'The staff are Ok. They do their best to help us and they are there when you need them.'

People said staff did everything needed to support them with their day- to- day living. We observed staff continually working to support people with all aspects of care. We observed staff communicating and interacting well whilst supporting people. This included ancillary staff, such as maintenance and domestic persons who were also seen to interact well with people living at the home. People's preferences and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

We saw that people were supported to complete a range of daily activities and this included support with social activities. Social activities were organised on a daily basis on all of the units. People were supported as their care needs changed. This was particularly evident with changing medical and nursing care needs.

Following our last inspection in January 2014 we had made some compliance actions [requirements] that the service needed to respond to and address. We found that most of these had been addressed and the improvements made. For example, the systems used by managers to monitor the quality of the service had improved. The homes manager had a range of easily accessible information to help monitor and plan any changes needed to improve the service.

Is the service well-led?

The service had a quality assurance system. This included both internal and external audits by senior managers. The system of audits had improved from our last inspection and information to help support management decisions was more readily available. Records seen by us showed that identified shortfalls were being addressed. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes that were in place. This helped to ensure that people received a good quality service at all times.

15 January 2014

During a routine inspection

We spoke with people about the service they received. They told us they were happy with the way staff supported them and the tasks they carried out for them.

Those we spoke with said the staff knew what support they required and did everything that was needed for them. One person told us, 'The staff are very good and are on hand to help me with my care when I need it. I don't have to wait long when I use the call bell.'

We reviewed how people's medicines were being managed. We found people were not protected against the risks associated with medicines because the provider's arrangements to manage medicines were not consistently followed.

We spoke with staff. They told us they had received relevant training and understood how to report abuse. They felt supported in their job although some staff were not supported through formal systems of supervision and appraisal from their manager.

We asked people who used the service about the skills of the staff. They told us the staff worked very hard and knew how to do their job. They felt staff were competent.

We found there were systems in place to monitor the quality of service that people received. These were not however analysed in enough detail to always identify and highlight key areas of need for improvement.

5 December 2012

During a routine inspection

We reviewed all of the information we held on the six units within St Nicholas Nursing Home. Based on this information we carried out an inspection of the two dementia care units.

The home took account of people's status in terms of decision making and worked closely with people, their families and external professionals. People using the service had regular assessments of their capacity to make decisions and these were carried out for different situations and reviewed regularly.

We looked at seven care records of people living in the two dementia care units of the home and we saw that up to date and person centred care plans were in place which supported staff to be able to deliver the care required. People living in the home spoke positively about the care they received.

Staff we spoke with were knowledgeable about managing medication and confirmed that they received training and read the policies and procedures before administering medication. Staff we spoke with told us they had good access to training to help them carry out their work.

Staff we spoke with told us that staffing levels and skill mix were appropriate and supported their delivery of care. We found information leaflets were available for visitors explaining how to make a complaint directly to the unit, the home or to the provider.

21 October 2011

During a routine inspection

People living at the home told us that they were provided with good care, by a kind and caring staff team and the care was given in a way that they preferred. They also said that there were insufficient staff and sometimes had to wait for their care needs to be met. All people spoken to said that they felt safe in the home and that they had no concerns.