Archived: Mount St Joseph - Leeds

We found the following examples of good practice.

The home had policies and procedures to manage any risks associated with the COVID-19 pandemic. This included the management of risks for people who had tested positive for COVID-19.

The provider had reorganised how regular activities were developed, making use of audio visual resources, to ensure people continued to enjoy activities in a safe way and in line with current guidance.

The environment had been adapted to comply with guidance and ensure people and relatives were able to continue interacting safely.

The provider had implemented a regular programme of COVID-19 testing for people in the home, staff, and visitors. All visitors, including professionals, were subject to a range of screening procedures, including showing evidence of vaccination and a negative lateral flow test before entry into the home was allowed.

Staff had received updated training on the use of PPE, and we observed staff wearing it correctly during our inspection. Clear signage and information was in place throughout the home to remind staff of their responsibilities.

The service had established good working relationships with relevant healthcare professionals and their support continued during the pandemic.

Workforce pressures were not having a detrimental impact on the delivery of the service.

Mount St Joseph is a care home providing personal and nursing care for 43 older people. The service can support up to 46 people.

The home is situated close to Leeds city centre and is close to bus routes, shops and other local amenities. The home has various communal and quiet sitting rooms and provides accommodation in single and double rooms.

People’s experience of using the service

People were supported safely and protected from harm. There were systems in place to reduce the risk of abuse and to assess and monitor potential risks to people.

The management of medicines was safe. Risk assessments had been completed and provided detailed guidance for staff to follow. Incidents and accidents were managed effectively; lessons learnt were shared with staff to reduce the risk of further occurrences.

There were enough skilled and experienced staff to meet the needs of people who used the service. Recruitment checks were completed on new staff to ensure they were suitable to support people who used the service. A comprehensive induction and training programme was completed by all staff.

People told us they felt cared for by staff who treated them with respect and dignity. People told us they were involved in their care, and what they did on a day to day basis. People's right to privacy was maintained by the actions and care given by staff members.

Staff understood people’s likes, dislikes and preferences and people told us they were offered choices about their care.

Where required, people were supported to have sufficient food and drink and their health needs were regularly monitored. Staff followed the advice health care professionals gave them.

Staff understood their responsibilities in relation to the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive was possible; the policies and systems in the service supported this practice.

A complaints system was in place and people felt confident to share any concerns with the management team.

The provider had embedded quality assurance systems to monitor the quality and safety of the care provided. People were asked for their views and their suggestions were used to improve the service.

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

Rating at last inspection

The last rating for this service was requires improvement (published 27 July 2018) and there was a breach of regulation. At this inspection we found improvements had been made and the provider was no longer in breach of regulation.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

Mount St Joseph - Leeds accommodates up to 45 older people and is situated in the Headingley area of Leeds. Mount St Joseph - Leeds is a residential home providing accommodation for persons who require personal care, some of whom are living with dementia. At the time of our inspection, 45 people were using the service.

This inspection took place on 25 and 30 May 2018. The inspection was unannounced on the first day. This meant the staff and provider did not know we would be visiting. The second day was announced.

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

We found improvements were needed as not all audits were being followed up with actions taken to drive improvement within the home and some had not been completed consistently. Some records were not always accurate and we found two notifications that had not been sent to the CQC to inform us of incidents that had occurred in the home.

During the inspection these notifications had been sent to the CQC. This related to the failure to notify us of other events and incidents which had occurred at the service which the provider is legally required to inform us of. We will deal with the notification issue outside of this inspection process.

Medicines were managed safely. As required' medicines were administered accordingly and protocols were in place for staff to follow.

People told us they felt safe and staff had a clear understanding of the procedures relating to safeguarding and whistleblowing.

Staffing levels were sufficient to meet people's needs and recruitment procedures were robust to ensure new staff were eligible to work with vulnerable people.

The majority of risk assessments were completed and reviewed to support people with specific needs to avoid any harm. We found one risk assessment which had not been updated however; this was completed before the end of our inspection. Incidents and accidents were monitored and managed safely with actions taken.

The provider followed The Mental Capacity Act 2005 with capacity assessments documented and best interest meetings recorded, when required. We found consent was obtained from people verbally and formally at review meetings.

People were supported with their health and nutritional needs and were provided with choices of food and drink at regular times throughout the day.

Staff were kind and caring. People said staff attended to their needs and that call bells were answered in a timely manner.

Care plans were detailed and included people's preferences, likes and dislikes, which promoted person centred care. People were encouraged to be independent and make choices regarding their care and staff respected people's privacy and dignity whilst tending to their care needs.

Complaints had been responded to in a timely manner with outcomes recorded and investigations completed when needed. Several compliments had also been received by the home.

Staff had completed training to ensure they met people’s care and support needs and this was in accordance with the providers policy. Staff were also supported with supervisions and annual appraisals to monitor staff to encourage and develop opportunities.

Staff told us they felt supported by the registered manager and felt confident to raise any concerns. Staff meetings took place and regular meetings with people living in the home to gather people’s views.

Surveys were provided to people, their relatives and health practitioners to gather their views of the service.

Further information is in the detailed findings below.

Mount St Joseph's is a purpose built home that provides nursing care. It is registered to provide care for up to 46 people in the Headingley area of Leeds. It is close to local amenities and bus routes. Accommodation is provided on two floors that are accessed by taking the stairs or lift. All bedrooms are single usage and all have en-suite facilities. Overnight visitors can usually be accommodated.

At the time of the inspection, the service had a manager registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

There was a rolling programme of training available which included; mental capacity act, safeguarding vulnerable adults, medication, moving and handling, first aid, nutrition and hydration awareness as well as dementia awareness. However we found gaps in the staff training schedule.

People told us they felt safe. Staff had a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines safely.

We found there were systems in place to protect people from risk of harm and appropriate recruitment procedures were in place. There were policies and procedures in place in relation to the Mental Capacity Act 2005.

There were enough staff to keep people safe. Staff told us they received training and support to fulfil their roles.

Safe recruitment procedures were in place to ensure only staff suitable to work in the caring profession were employed. This included ensuring a Disclosure and Barring Service (DBS) check and at least two written references were obtained before staff started work.

People told us they received the support they needed with meals and healthcare. Health, care and support needs were effectively assessed. People had regular contact with healthcare professionals; this helped ensure their needs were met.

People were supported by staff who treated them with kindness and were respectful of their privacy and dignity. People participated in a range of activities and were able to choose where they spent their time.

The service had good management and leadership. People were provided with opportunities to comment on the quality of service and influence service delivery. Effective systems were in place which ensured people received safe and quality care. Complaints were investigated and responded to appropriately.

There was an effective quality assurance monitoring system in place to identify any shortfall in the service.

A breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was found during this inspection. You can see what action we told the provider to take at the end of this report.

We used this information to answer the five questions we always ask;

' 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?

The relatives we spoke with raised no concerns about people's safety and said if they had concerns they would discuss them with management.

People were treated with respect and dignity by staff. One person said, 'I have no concerns here, everyone is so nice, we are treated very well.'

Staff we spoke with had a clear understanding of their roles and responsibilities within the team, and were knowledgeable about the service.

In the main, care and support was planned and delivered in a way that ensured people's safety and welfare. Care files identified risks and how these were managed.

Overall, the service was clean and hygienic with systems in place to ensure people were not put at risk from infection.

Is the service effective?

People's files contained pre-admission assessments, which showed people's health, personal and social care needs were assessed before they moved into the home.

Staff described how they met and monitored people's health needs. Care records showed people had regular contact with health and other professionals.

When people were identified as being at risk, their plans showed the actions required to manage these risks. These included the provision of specialist equipment such as pressure relieving mattresses, hoists and walking aids.

Relatives told us they were well informed about their relative's care and treatment and were involved in their regular care plan reviews. They told us the staff were helpful and kind. They said the staff were quick to inform them of any significant changes in their relative's general health.

Visitors confirmed they were able to see people in private and visiting times were flexible.

Is the service caring?

Visitors we spoke with told us they were very happy with the care provided and in their opinion people were well looked after. They described staff as friendly, patient and caring.

We observed staff supporting people who used the service. Staff were friendly, patient, polite and treated people in a respectful way. During lunch staff encouraged people to be independent and make choices but at the same time assisted people when they required support.

People who used the service were asked about their care and able to make decisions. They were supported by kind and attentive staff.

We found the care staff we spoke with demonstrated a good knowledge of people's needs and were able to explain how individuals preferred their care and support to be delivered. We saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.

Is the service responsive?

People's needs were assessed and care and support was planned and delivered in line with their care plan. Care records contained good information about how care and support should be delivered

People and their families were involved in discussions about their care and the risk factors associated with this. Individual choices and decisions were documented in the care plans and reviewed on a regular basis.

People who used the service told us they knew how to complain or raise concerns if they had any.

We saw people who used the service were responded to promptly when they asked for any support or assistance

People were supported to be involved in a good selection of activity of their choice within the home.

Is the service well-led?

Staff said they felt the service was well managed and the management and provider were approachable. They said they had confidence any issues brought to their attention were always dealt with properly and thoroughly. Staff said they understood their role and what was expected of them.

The provider had an effective system to regularly assess and monitor the quality of the service people received. We looked at a selection of reports which showed the provider had assessed and monitored the quality of service provision.

Care and support was planned and delivered in a way that ensured people's safety and welfare. Care files identified risks and how these were managed.

During our observations we noted positive interaction between the staff and people who used the service. We observed when people needed support; staff provided this in a sensitive and friendly way.

Care staff were able to tell us about how they met the different needs of people. They told us about the training they received to make sure they were able to care for people's care needs.

A staff member told us "This is a friendly home some staff come in even when they are not on duty to take part in activities.'

There were effective recruitment and selection processes in place. The provider had recruitment policies and procedures which the home followed when employing new members of staff. These were detailed and clearly identified what checks must be carried out before staff were employed to work at the home.

The manager kept records of all complaints, the records showed us complaints were investigated and responded to.