St Katharine's House

St Katharines House is a residential care home providing personal and nursing care to up to 76 people. The service provides support to older people across 3 wings, some of who lived with dementia. At the time of our inspection there were 61 people using the service.

People’s experience of using this service and what we found

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff understood when the principles of the Mental Capacity Act should be applied. However, we found recording of mental capacity assessments could be improved.

We have made a recommendation about recording in line with the principles of the MCA.

People told us they felt safe living at St Katharines. Staff knew how to identify and report any concerns. The provider continued to recruit staff and had safe recruitment and selection processes in place.

Risks to people's safety and well-being were managed through a risk management process. There were sufficient staff deployed to meet people's needs. Medicines were managed safely, and people received their medicines as prescribed.

People received personalised care, tailored to their individual needs and preferences, and staff supported people and their relatives to be involved with decisions relating to their care. People were supported to take part in a variety of activities and hobbies both internal and external. People's communication needs were known and met by staff who knew people well. People, their relatives and staff were asked for their opinions of the service and action was taken to make improvements. Complaints were recorded and investigated.

The home was well-led by a registered manager who was committed to improving people’s quality of life. They, and the provider had made significant improvements and had further plans to continuously improve people's care. There was a clear management structure in place and staff worked well as a team. The provider had clear oversight of the service and effective quality assurance systems in place that they used to monitor the quality and safety of the service. Staff worked well with external social and health care professionals.

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

Rating at last inspection and update

The last rating for this service was requires improvement (Published 18 July 2019)

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 30 May 2019.

We undertook this focused inspection to check the provider had made improvements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Katharines House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

St Katharine’s House is a care home that was providing personal and nursing care to 46 people aged 65 and over at the time of the inspection.

St Katharine’s House accommodates up to 76 people in one adapted building. One unit in the service specialises in providing care to people living with dementia.

People’s experience of using this service and what we found:

People were protected from the risk of harm by staff who understood their responsibilities to report concerns. Improvements had been made to risk assessments and risks to people were managed effectively. There were sufficient staff deployed to meet people’s needs. Medicines were managed safely. Improvements had been made to ensure people were protected from the risk of infection.

There had been changes in the management of the service which had resulted in improved systems to monitor and improve the service. Everyone was positive about the manager and the person-centred culture they promoted. The manager was improving links with health professionals and the local community.

People’s care plans had been updated and reflected current needs. Care plans included people’s wishes relating to end of life care. People enjoyed a range of activities and were encouraged to participate in the life of the home. People and relatives were confident to raise concerns and all complaints were dealt with in line with the provider’s policy.

People enjoyed the food and specific dietary needs were met. Staff were well supported and had the skills and knowledge to meet people’s needs. The provider ensured people’s needs were met in line with current practice and guidance. People were supported to have access to a range of health and social care professionals.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff were kind and compassionate. People’s dignity and privacy were respected, and their rights upheld. Staff ensured people were involved in all aspects of their care and respected their choices. People were encouraged to maintain their independence.

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

Rating at last inspection and update:

The last rating for this service was inadequate (published 18 December 2018) and there were two breaches of regulation. CQC took enforcement action to ensure the provider took action to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 18 December 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

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

St Katharine’s House is registered to provide accommodation for up to 76 people who require nursing care. At the time of the inspection there were 55 people living at the service.

At the time of the inspection there was no 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 carried out an unannounced inspection of St Katharine’s House in December 2017. Following our inspection in December 2017 we published a report in which we rated the service as requires improvement. During our December 2017 inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations (2014). This related to incomplete and inaccurate care records. At this inspection we found that the service had failed to address the concerns.

There was not an effective system in place to monitor call bell response times. The provider's procedures to formally assess, review and monitor the quality of the service were not always effective.

Risk assessments were not always accurate, complete or up to date. People were not always protected from risk due to environmental hazards. Medicines prescribed to people were not always held in stock and were not always stored securely.

People were not always protected from the risk of infection. The premises and the equipment were not always clean, and staff did not always follow the provider's infection control policy to prevent and manage potential risks of infection. Equipment was not always maintained in line with manufacturer's guidance.

Records relating to people’s care were not always accurate and complete. Care records did not always contain guidance provided by other healthcare professionals.

Where people required special diets, for example, pureed or fortified meals, these were provided by kitchen staff who understood the dietary needs of the people they were catering for. However, people did not always receive person-centred support at mealtimes.

People we spoke with told us there was a constant change in management and that the service was not always well led. Staff had not completed training on planned dates to ensure that their knowledge and practices were up to date.

The service did not always respond effectively to people’s changing needs. Care records did not always capture person centred information about people's backgrounds, hobbies and interest and daily routines.

People had access to activities that included live entertainment. We observed people enjoying some live entertainment. People knew how to make a complaint and information on how to complain was available in the home.

The service supported people in line with the principles of the Mental Capacity Act (2005) and the service followed the correct procedures when depriving people of their liberty.

People and their relatives told us they benefited from caring relationships with the staff who supported them. There was good communication between staff and the people who used the service. Staff received regular supervision, which is a one to one meeting with their manager.

The overall rating for this service is 'Inadequate' and the service is in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel their 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 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.

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We are taking further action in relation to this provider and full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations have been concluded. In the interim we have asked for and received a plan from the provider telling us how they are going to address these concerns to inform our ongoing monitoring of this service.

St Katharine's House is a care home providing care for up to 76 people. At the time of the inspection there were 59 people using the service.

At the time of the inspection there was no 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. The home manager told us they would be applying to register with the CQC.

People's care records were not always kept up to date and did not always reflect changes in their care needs. Records relating to assessed risks were not always kept up to date and care plans did not always contain up to date plans relating to how risks were managed.

There were sufficient staff deployed to meet people's needs. People commented on the number of agency staff working in the service and the provider was proactive in looking for ways to recruit permanent staff. Changes had been made to the rota for permanent staff to ensure there was an appropriate skill mix to meet people's needs.

People received their medicines as prescribed by staff who were trained and competent to do so. Infection control measures were in place to protect people from the risk of cross infection.

We saw people enjoying their meals and they were positive about recent improvements made to the food and drink. Where people had specific dietary requirements these were provided.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff were supported through regular supervision and had access to training and development to ensure they had the skills and knowledge to meet people's needs. Staff felt valued and were involved in the development of the service.

People were treated with dignity and respect by staff who were kind and compassionate. People were complimentary about staff and had developed positive relationships with staff and others. We observed many kind and caring interactions where staff displayed their understanding of people's needs and knowledge of them as individuals.

There were a range of activities taking place during the inspection and we saw people enjoying them. People were positive about the activities team and the effort made to ensure people were able to access activities that interested them.

The manager was passionate about the service and was committed to making improvements. Staff felt valued and listened to and were complimentary about the manager and the changes they had made.

There was an open culture which was promoted through the provider's vision and values. People were seen as unique individuals and the service promoted a culture of inclusiveness that valued everyone as individuals.

There were systems in place to monitor and improve the service and we saw that where issues were identified action was taken to improve. However, the systems had not identified the issues we found during the inspection.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

St Katharine's House is registered to provide accommodation for 76 older people who require nursing and personal care. The home is arranged into three units; Willow Walk, on the first floor of the main building provides care for people living with dementia, St Luke's Wing provides nursing care for people with nursing needs, whilst the ground and second floor of the main building provide residential care for elderly people.

On the day of our visit there were 51 people living at the home. We spoke with ten people who used the service, three people's relatives and twelve staff. We observed care and treatment and looked at ten care records. We also carried out a short observational framework for inspection (SOFI). A SOFI is used to capture the experiences of people who use the service who may not be able to express this for themselves.

The inspection team who carried out this inspection consisted of three inspectors and a specialist advisor in dementia care. During the inspection, the team worked together to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

There was no evidence that care was not safe. However, although significant improvements had been made to peoples care records we found that some people were still at risk of inappropriate care because accurate and comprehensive information about their care was not being always being recorded. We spoke with senior management who advised us that the continued issues with the care records had been identified in the manager's audit and raised at staff meetings. We have asked the provider to continue making improvements and we will return to the home to check these have been made.

Systems were in place to make sure that managers and care workers learnt from events such as accidents, incidents and complaints. This reduced the risks to people and helped the service to continually improve.

The provider understood their responsibilities under the Mental Capacity Act 2005 in relation to the Deprivation of Liberty Safeguards (DoLS). The acting manager was aware of the recent Supreme Court judgement in relation to the Deprivation of Liberty Safeguards and told us that in light of the judgement they were reviewing whether some people would require a DoLS application to be made.

Is the service effective?

Effectiveness relates to how well the planned care works for people. Because record keeping was not always complete it was not possible to assess if planned care was always effective. People told us that they were happy with the care they received and felt their needs had been met. It was clear from what we saw and from speaking with nurses and care workers that they understood people's care and support needs and that they knew them well. We found that nurses and care workers had received training to meet the needs of the people living at the home.

At our previous inspection we found that nurses and care workers did not demonstrate a good understanding of consent, mental capacity and how these applied to their practice, and to people's needs. At this inspection we found that the provider/service has made progress in supporting people to be involved in decision making, and further improvements are planned. However, they have not yet achieved this to a satisfactory standard and we would want to continue to monitor this.

We had also previously found there were not suitable arrangements in place to ensure that nurses and care workers were supported to deliver care through receiving appropriate supervision and appraisal. At this inspection we concluded that nurses and care workers received appropriate support to enable them to undertake their duties.

We have asked the provider to continue making improvements to the effectiveness of the service and we will return to the home to check these have been made.

Is the service caring?

The service was caring and care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We spoke with people about the care they received. One person said, 'I like living here, the carers are really nice'. Another said, 'It's absolutely perfect'. Another said, 'there have been lots of changes, it's been worrying because I've been here a long time, but it has been for the better'. We spoke with a relative who said, 'staff are lovely, very caring, really know what they are doing'. Another said, 'I am very pleased with the care, I can't fault it'. During our SOFI observation we saw that people were given choices, supported to make decisions and care workers took time to understand people where they had communication difficulties. Throughout our inspection the atmosphere was pleasant and we observed many interactions between care workers and people that were caring, relaxed and friendly.

Is the service responsive?

The home was responsive. We saw evidence that nurses and care workers recognised when a person's condition changed or their health had deteriorated and sought the help and advice of the medical team or other professionals.

We found that people were mostly engaged in meaningful activity. However, we found that people living with dementia on St Luke's nursing wing did not benefit from the same type and level of activity as those living with dementia on the Willow Walk dementia unit and we have asked the provider to take note of this.

Is the service well-led?

We cannot say this service was well led, despite the improvements and changes that had been made. This was because this service is required by law to have a registered manager and has not had one since September 2013. The interim management team were continuing to take appropriate steps to improve the service and lead its development, however it was too soon to be able to see if these changes were embedded and sustained.

At our previous inspection we found that the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service. Following our visit we issued the provider with a warning notice stating that they must take action to address these risks. At his inspection we saw that significant improvements had been made. We spoke with the acting manager who outlined the range of quality monitoring systems in place to review the care and treatment offered at the home. We saw evidence of how these quality monitoring systems were used to make improvements to the home. The provider may find it useful to note that although a monthly audit of the care records was completed a follow up of individual records did not take place to check that any identified actions had been carried out.

At our visit on 3 March 2014 we found that action had been taken by the provider in relation to the concerns raised. An assessment of the risks associated with one person's choice not to follow professional recommendations with respect of drinking had been undertaken. Measures had been put in place to reduce and manage these risks. We spoke with care workers who understood the risks and were able to describe the actions they would take to ensure that people who were at risk of choking were safe.

During our visit on 3 March 2014 we also looked more broadly at the care and welfare of people who used the service. We spoke with seven people who used the service and three people's relatives. People told us they were happy living at St Katharine's House. Comments included; 'you won't get a better home than this' and 'it's very good. No complaints'. Relatives gave us a mixed opinion. Whilst one raised concerns that their relative was not supported to drink enough , others were very positive about the care provided. One said 'staff are good, everyone knows her [their relative], knows how to look after her and they look after her very well'. We spoke with eight care staff, three kitchen staff and the senior nurse. Care staff told us there had been changes and improvements within the home, particularly with respect to planning and delivery of care. One said 'the care plans are so much easier to understand now. We had training on the care plans, a few months ago and now I know where to find all the information I need'.

We looked at how the risk of people not eating and drinking enough was managed within Willow Walk. We saw that people, who had been assessed as being at risk, were having their food and drink intake monitored. We saw that where concerns had been identified that people might not be eating and drinking enough, appropriate action had been taken. Professional advice had been taken and the recommendations made were being followed by care workers in accordance with those recommendations. We found some specific concerns with respect of one person and passed these on to the unit manager so that they could be immediately assessed. We saw that where management plans had been put in place with respect of people's skin integrity, appropriate equipment was in place and care workers were acting in accordance with the plans. Care and treatment was being planned and delivered in a way that ensured people's safety and welfare.

We visited St Katharine's House on 25 November 2013 and found that improvements had been made. Staff had received training in nutrition. We saw that people's nutritional and hydration needs were being assessed and care was planned and delivered to ensure people drank and ate enough. However, we found that two people, within the nursing wing, were not having the risks to their health and safety fully managed. We asked the provider to take action and they did. We shared our concerns about one person with the local authority safeguarding team.

We returned to St Katharine's House on 5 December to look more broadly at the systems in place for meeting people's needs and addressing issues of quality and safety. There were three inspectors who looked at care in each of the three separate units; nursing, residential and dementia care. We found that the care in the residential and dementia units was reaching the standard of care expected. However, issues remained in the nursing wing.

56 people were living at St Katharine's House, we spoke with 10 people, one relative and six members of staff. A relative said 'it's definitely a lot better'. People we spoke with said 'I'm very happy here'; 'it's okay, it's a good place to be' and another said 'the care team work very hard at putting things [activities] on'. We found evidence across all three units that people's needs were assessed and care and treatment was planned and delivered on the basis of those assessments. We saw that whilst improvements had been made to ensure care and treatment was delivered in a way that met people's needs, sufficient actions had not been taken to address the safety needs of two people on the nursing unit.

As a result of the concerns about two people's safety identified on 25 November, we looked more broadly at the systems the provider had in place to identify, assess and manage risks. The provider was not operating systems in a way that ensured that they always identified risks for themselves. We were concerned that the provider was not always identifying the potential for people to be unsafe. We were concerned that because systems were not effectively operated, the provider had not been able to address why they had not met the regulations, set out to ensure people received safe and effective care, since 2011.

We identified concerns in three other areas of care and have told the provider to take action. These were: the system for obtaining informed consent and acting upon it, the provision of appropriate supervision and appraisal for staff and the accurate keeping of records in relation to care.

We found that staff knew their responsibility with respect to safeguarding people and the service acted in accordance with their policy and in conjunction with the local authority.

We liaised with the local authority quality and contracts manager who had received reports from a number of professionals involved with St Katharine's House. They concluded that significant improvements had been made to the way people's care needs were being met. However, further improvements were required, specifically with respect of identification and management of risk. For that reason the local authority were continuing to not place any new people at the home. This means that they will not support anyone else to live at this home until St Katharine's have made the required improvements. In addition they have put monitoring arrangements in place. CQC have received written confirmation that St Katharine's House would not be admitting any new people through private arrangements until they had put in place systems to ensure people's safety. CQC can take additional enforcement actions if this service does not identify and manage risks and meet people's needs safely.

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

We visited to follow up on two areas of non-compliance identified at our visit in May 2013. These were in relation to the planning and delivery of care and the maintenance and reliability of the lift. We also looked at how the service respected and involved people. We spoke with four people who used the service, one relative and looked at 10 care plans. People told us that they were happy with the care they received. However, records indicated that care was not being planned and delivered to ensure the welfare and safety of people.

The risks to some people from becoming malnourished or dehydrated were not always being managed in a way that sufficiently reduced or managed the risks.

We found that improvement had been made since our last inspection with respect to the environment and activities within Willow Walk, the unit for people living with dementia.

The lift had been unreliable for a long period of time and the provider told us that the lift had been refurbished and would be operating by 26 September 2013. On 1 October 2013 the lift was not working and repair work had not been completed. However on 2 October 2013 we were told it was working and we confirmed this by visiting and checking.

We found care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare. Where risks had been identified these had not always been addressed. The variable quality of entries meant that nurses and care workers could not be sure that care was being delivered in line with individual care plans.

We found that the lift had been out of order on 11 occasions since our previous visit. We spoke with one person whose relative was disabled and used a wheelchair. Their relative had been unable to visit on a number of occasions due to the lift breaking down.

We found that staffing levels in the home had improved since our previous visit. One relative we spoke with told us 'there was a time when there weren't enough staff, six months ago'.

We found improvement in record keeping. Records were organised in a way that made easily accessible for care workers. One care worker told us 'the files have improved and it is easier to find records in the file'.

People we spoke with during the visit expressed concern about the number of staff available to work on the dementia unit. Concern was also expressed about the imminent departure of the unit manager. We also found that a newly installed bath was out of order and the sluicing facilities were also not working.We asked for an action plan. We were told the hot water was back up to heat the following day. No action plan was received for the installation of the bath or sluicing facilities.

We have made compliance actions.

The home has been placed on Red Alert by Oxfordshire Social Services Commissioning who will not place anybody in the home until improvements have been made.