Archived: St George's Nursing Home

St George's Nursing Home is registered to provide both nursing and residential care with accommodation for up 43 people. People who live at St George's Nursing Home all had needs relating to their health, and some people were also living with dementia. At the time of our inspection there were 11 people living at the home.

A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had recruited to the role of home manager and this manager was in the process of registering with the Care Quality Commission [CQC].

At our previous inspection on 20 and 21 April 2016, we found five breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. These breaches were in relation to person centred care, safe care and treatment, premises, staffing and good governance. The home was placed in 'Special Measures.' The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months.

We also took enforcement action by imposing a condition on the provider’s registration to restrict admissions to the home. This was because of the significant concerns about the safe care and treatment of people who lived at the home.

At this inspection we looked to see if the provider had responded to make the required improvements in the standard of care to meet the regulations. Whilst we found areas of improvement had been made to meet some of the regulations the provider continued to be in breach of the legal requirements and regulations associated with the Health and Social Care Act 2008. These were in relation to safe care and treatment and good governance.

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

The provider had management procedures in place but these were not consistently effective. Where improvements were required these had not always been assessed for their effectiveness and sustainability. At this inspection we found there was a continued lack of a consistent strong vision and oversight of the service to support people in receiving safe, effective and responsive care which was well led.

We found there were inconsistencies in the provider's systems and staff practices to provide assurances that all risks to people were safely and effectively managed. We found the management oversight of incidents did not provide confidence in how these were consistently followed through. There were aspects of staff practices which did not assist in the prevention of reducing cross infections and accessible items could place people at risk of harm.

The provider had employed a maintenance person who had assisted in the improvements in the repairs within the home. Since our previous inspection work had been carried out on the water supply so the risks to people of scalding and/or their personal care needs neglected had been reduced. The temperature of the hot water supply had been regularly tested by the maintenance person.

People’s medicines were stored securely and made available to people as prescribed. Safety measures had been put in place to make sure staff no longer carried used needles around the home environment. Further improvements were required to ensure the practices adopted when administering medicines was consistently undertaken in line with the provider’s medicine policies and procedures.

People had different reasons for feeling safe whilst living at the home which included feeling having staff available so they could request support. Staff told us they understood how to recognise abuse and would report concerns to the manager.

We saw staffing arrangements made sure staff were available to assist people in meeting their needs at times they required. The provider employed agency staff to fill any gaps in the daily staff rotas. There was some inconsistencies in the arrangements to make sure there was a cook in the kitchen to make sure people’s nutritional needs were effectively met although the manager had undertaken recruitment to fill this post.

Staff training continued to require improvement to ensure all staff had the opportunity of receiving regular training. We saw staff did not always apply their knowledge into their daily practices to effectively meet people’s needs. Although there were some measures in place to check the effectiveness of staff’s competencies these needed to be embedded into all aspects of staff’s nursing and caring roles.

Health and social care professionals were involved in people's care to ensure they received the care and treatment which was right for them. This included nutritional advice and support where required to meet people’s needs.

People were asked before support was provided and their wishes were respected. We saw people were given choice about day to day decisions such as what they would like to wear and where they would like to sit. However, there were inconsistencies in assessing people's ability to make their own decisions. Where decisions had been made on people's behalf the records did not always reflect whether best interest decisions were made by people who had the authority to do this.

The manager was aware staff’s caring practices required further improving to make sure people’s dignity was maintained. The manager and staff had made improvements to the home environment. They recognised there was more to do, such as signage to further support people’s independence and meet the needs of people with dementia. There were no plans in place to progress these improvements. These would need to be implemented and caring practices sustained over time.

Work was in progress to update people’s records so they accurately reflected their individual needs to assist in guiding staff’s daily practices. Record keeping required further strengthening so there were assurances these would be met at the right time and in the right way. There were inconsistences in how people’s care and health needs were accurately recorded especially where people’s needs had changed.

The activities co-ordinator employed by the provider was assisting in the improvements for people to have fun and interesting things to do. Opportunities for people to follow their own interests and socialise was continuing to be embedded into daily life.

At the last inspection in April 2016 the home had an overall rating of inadequate and the provider was placed into special measures by the Care Quality Commission. After six months we have re-inspected and one key question remains as inadequate. As a consequence the service remains in special measures.

This service will continue to be kept under review and, if needed we will take further action in line with our enforcement procedures preventing the provider from operating this service. Where necessary, another inspection will be conducted within a further time period, and if there is not enough improvement and there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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

St George’s Nursing Home is a care home and the provider is registered to provide both nursing and residential care with accommodation for up 43 people. People who live at St George’s Nursing Home all had needs relating to their older age, and some people were also living with dementia. At the time of our inspection there were 19 people living at the home.

A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had recruited to the role of home manager and this manager was present at the time of our inspection.

At this inspection we found the provider was in breach of four of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were Regulation 12 in relation to safe care and treatment, Regulation 18 in relation to staffing, Regulation 9 in relation to person centred care and Regulation 17 in relation to the governance of the service. These breaches in Regulations are described throughout all sections of this report.

People were not always kept safe from harm as risks to their wellbeing and safety were not identified and managed with timely action taken. The provider’s systems and staff practices did not provide assurances all incidents which placed people at risk of harm had been reported with the appropriate action to keep people safe.

People were put at increased risk of infections because the provider’s systems and staff practices did not ensure people lived in a clean and hygienic home. This included the equipment staff used to assist people and the furniture in the home to make sure people were not at risk from cross infections. Staff practices around carrying used needles around the home when they should be place straight after use in the appropriate container did not promote people’s safety from injuries or infections.

People’s safety and wellbeing was not promoted as there were hazards around the home environment and action had not been taken to reduce these. Staff practices did not make sure people were provided with safe and effective care due to the provider’s inconsistent water supply which meant staff carried hot water around the home increasing the risks of scalds.

People were supported with their medicines. Medicines were ordered, stored, administered and disposed of safely. Staff did not have detailed information about people’s when required medicines

People received healthcare support to maintain their nutritional needs when required. The manager showed they led by example and was ensuring staff consistently assisted people with their meals where this was required as some people had been losing weight.

People were supported to make choices about their everyday care and support. There were some procedures in place to ensure where people were not able to make specific decisions themselves in their best interests. These were not always effectively organised to enable staff to easily access this information and to ensure people’s rights were upheld through staff practices.

Staff had some positive caring conversations with people which enhanced their wellbeing. Other staff practices were based around tasks as opposed to considering each person’s feelings. People’s privacy was promoted by staff who recognised and respected.

Staff did not have the confidence or knowledge to respond to the identified needs of some people who had come to live at the home. The provider had not made sure before agreeing individual people’s needs could be met at the home they had increased staff’s knowledge and tested their competence in providing the individual care people required.

The provider did not show they were caring and accountable as they had not informed the Care Quality Commission when they decided to provide care to people with learning disabilities and specific mental health conditions.

The provider failed to make improvements to the service which had been brought to their attention by a number of different agencies. Insufficient systems were in place for the provider to monitor the quality of the service to ensure people consistently received safe and effective care.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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

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

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

The fire officer, contracts officer and health and safety officer from the local authority were present at the time of this inspection.

We talked with the provider, the home manager and the quality assurance and safety support manager about the improvements that had been made to the premises and facilities. We also looked at some quality checks and service histories that had been completed for the premises and equipment.

We considered all of the evidence that we had gathered under the outcome that we inspected around the suitability and the safety of the premises to answer one of the five questions we always ask;

Is the service safe?

We saw that the provider had carried out significant refurbishment and redecoration work at the home so that the premises and facilities were suitable and safe for people who come to live at the home. To ensure future repairs and improvements are completed we saw the introduction of monitoring and quality checks. We saw that the provider had introduced a responsive and planned approach to make sure that the premises and facilities were consistently developed, reviewed and improved as required to meet the needs and safety of people who come to live at the home.

At this inspection we did not speak with people who lived at the home as we wanted to be sensitive to their needs at this difficult time. However, we spoke with the manager, operations manager and some staff who worked at the home. The management team and the staff that we spoke with told us that people who lived at the home received care and support from staff that met their needs.

We spent time with the new staff member who had delegated responsibility for the maintenance of the home environment. They showed us the repair work that needed to be done. We saw that some of the work had been outstanding for a period of time. However we could not find a responsive and planned approach to get the repair work done that made sure The Hall Nursing Home was a suitable and safe place for people to live.

We also looked at the quality assurance arrangements the provider has in place to check the premises. We found that these did not effectively identify the shortfalls in all the maintenance work required to ensure that any work and repairs were dealt with in a responsive and timely way. This meant that the homes environment was not always consistently developed, reviewed and improved as needed to meet the needs and safety of the people who lived at the home.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still the Registered Manager on our register at the time.

Some people who lived at the home were unable to communicate their experiences and views about the care they received due to their complex needs. Therefore we spent time at the home to watch to see how staff supported people. We also looked at a selection of care records for five people who lived at the home, and spoke with three members of staff and the management team which included the provider.

People that were able to speak with us were positive about the care and support provided. One person said: 'If I need anything they (staff) will help me' and 'I like it here, I have no complaints.' Another person said: 'They (staff) always make sure I have drinks at hand in my room, I don't even have to ask.'

We also spoke with some relatives and friends who visited the home. A relative said, 'The staff are very particular about privacy and dignity. I think they're (staff) remarkable' and 'Recently I have seen activities getting better.'

We saw that staff were kind and caring in the way they supported people. Although staff were busy they took time to support people at their own pace with their daily routines. We saw examples where staff responded promptly to any requests for assistance and the ratios of staff were monitored to ensure this remained the case.

We observed the lunchtime and teatime meals. Overall there was a relaxed approach to mealtimes as we saw that people made choices what they would like to eat and where they would like to eat their meals. We also saw that hot and cold drinks were readily available for people throughout the day together with staff support where required.

People had a care plan that reflected their needs and their personal routines. We saw that staff got people's consent before they delivered care. We also noticed work was on-going to protect people who were unable to give their consent so that this was accurately recorded in their care records for staff to follow.

At this inspection we found that progress had been made in all the outcome areas where we had previously had concerns and improvements had been made.

Our inspection was unannounced; no one knew we would be visiting. We spoke with five people and five staff, the manager and operational manager to find out their views about the service provided at the home.

The people who lived at the home we talked with were happy with the quality of the care provided. One person said: "They (staff) help me and all do it with a smile".

People told us staff treated them with respect and dignity. One person told us: "They (staff) are all nice to me".

We looked at the medicine administration records for seven people and how the service stored and managed medicines. We found that arrangements were in place to ensure that medicines were managed safely.

There were processes in place to monitor risks to the quality and safety of care. There was evidence that learning from incidents took place and appropriate changes made.

During this inspection, we spoke with three people living at the home, the manager, the operational manager and five staff. Following our inspection we also spoke with four relatives.

We found that some improvements were being carried out that ensured people's needs were being met with identified risks reduced.

We observed that staff spoke with people who lived at the home in a respectful way. People who lived at this home who we spoke with told us they were happy with the quality of care and support they received. One person said, 'Food is okay' and 'Staff are very good and caring.' This person also told us that there were activities if they wanted to join in these but liked to also spend time in their room which they said staff respected.

We found that the medicine administration, management and practices were not effective and therefore people were at risk from not receiving their medicines as prescribed.

In this report the name of two registered managers appear who were not in post and not managing the regulatory activities at this location at the time of the inspection. Their names appear because they were still Registered Managers on our register at the time.