St Fillans Care Home

St Fillans is a residential care home providing personal and nursing care up to 71 people. The service accommodates people across four separate units, each of which has separate adapted facilities. At the time of our inspection there were 65 people using the service.

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

Our visits on 21 and 22 September 2022 found poor infection prevention and control (IP&C) practices relating to the wearing, storage and disposal of personal protective equipment (PPE). The cleanliness of the premises and equipment needed to improve, including the main and satellite kitchens. We wrote to the provider on 23 September 2022 to request an update on the action taken to address the infection control and cleanliness issues identified.

The provider took immediate action to purchase additional clinical bins, provide plastic wipeable boxes to contain PPE, and confirmed a full programme of cleaning had been completed, including a deep clean of kitchens. Guidance was provided to staff, and spot checks were being carried out to ensure the correct use of PPE, including wearing of masks. Our follow up visit on 30 September 2022 confirmed the above action had been taken to prevent the spread of infection and ensure the premises were clean.

Although the provider had taken immediate action to address the issues above, the governance systems were not always being used effectively to identify and drive the required improvements. The IP&C audit had not identified the issues we found during the inspection. The dementia audit had not identified the issues we found, relating to the complex care unit, Charter. There was no clear direction for staff, and minimal attempts to divert people’s behaviours using meaningful activities.

People’s care records contained conflicting information which exposed them to the risk of not receiving safe care. Behaviour support plans did not provide sufficient guidance for staff on how to support people to manage times of distress and anxieties.

The service was divided in to four units, St Johns, Castle, Dutch and Charter. Dutch and Charter on the first floor were not decorated consistent with the standard in St Johns and Castle on the ground floor, especially Charter the complex care unit. The environment in Charter did not always promote people’s quality of life and help them live well with their dementia.

We have made a recommendation about improving the environment for people living with dementia.

People were not always supported to have choice and control of their lives. People’s mealtime experience differed depending on which unit they resided. On Dutch and Castle units’ people were supported to choose when, where and what they wanted to eat. In St Johns and Charter people were not always offered a choice of meal or drinks. Staff were observed assisting people to eat from a standing position and getting up and down during mealtimes doing other tasks. This did not make the mealtime a sociable experience.

We have made a recommendation about staff training on the subject of dementia and improving people’s mealtime experience.

People, relatives and staff told us the frequent changes of managers had been unsettling and disruptive but were positive about the new management team. They told us communication and staff morale had improved. Managers and staff worked well with health professionals and other networks, such as Essex FaNs who had supported people to engage in personalised activities.

The service reviewed staffing levels regularly and had recruited new staff, reducing the need to use temporary agency staff. People had good access to healthcare and their medicines were managed safely. Systems were in place to safeguard people from the risk of abuse. Where things had gone wrong, investigations had been used as an opportunity to learn lessons, change practice and drive improvement.

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 Good (published 04 April 2018).

Why we inspected

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.

The inspection was prompted in part due to a number of concerns raised about management of the service about poor standards of care, lack of behaviour support plans, lack of staff training and the environment. A decision was made for us to inspect and examine those risks. 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 Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

There was a manager in post who had applied to become registered. 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.

At our last inspection in September 2016, we found a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to care plans not always reflecting people’s needs.

At this inspection we found that there had been improvements in this and people were receiving personalised care that was responsive to their needs. Care plans were written in a person centred manner and reflected the care and support each person required and preferred to meet their assessed physical and emotional needs. Further work was still needed to ensure that daily records were an accurate record of care being provided.

Staffing levels had improved since our last inspection although some people raised concerns that there were times when deployment of staff could be improved further on the Dutch unit, and we have received assurances that this will be monitored closely to ensure deployment of staff is effective to meet people’s needs at all times.

There was a positive, open and inclusive culture in the service. The atmosphere in the service was warm and welcoming. There were systems in place to minimise risks to people and to keep them safe. Staff were trained and supported to meet people’s needs effectively.

Staff understood the importance of gaining people’s consent and were compassionate, attentive and caring in their interactions with people. They understood people’s preferred routines, likes and dislikes and what mattered to them.

The management team and staff understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). 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.

People presented as relaxed and at ease in their surroundings and told us that they felt safe. Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. People knew how to raise concerns and were confident that any concerns would be listened and responded to.

People were complimentary about the way staff interacted with them. Independence, privacy and dignity was promoted and respected. Staff took account of people’s individual needs and preferences and people were encouraged to be involved in making decisions about their care.

People’s nutritional needs were assessed and professional advice and support was obtained for people when needed. They were supported to maintain good health and had access to appropriate services which ensured they received ongoing healthcare support.

People were provided with their medicines in a safe manner. They were prompted, encouraged and reassured as they took their medicines and given the time they needed.

The service had improved their quality assurance systems. These were used to identify shortfalls and to drive improvement. As a result the quality of the service was continually improving. This helped to ensure that people received a high quality service. The management team were open and transparent throughout the inspection and sought feedback to further improve the service provided.

The service provides nursing care and support for up to 71 people. On the day of our inspection there were 58 people living in the service.

The service is separated into four units. Two specialist dementia units, one nursing unit and one residential unit. There is free access between the units. If people’s needs change they are not moved unnecessarily.

The service had a registered manager. 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.

Care plans did not always reflect the care and support people required. Some care plans did not contain sufficient information to ensure people received the care and support they required. Information in some care plans was contradictory. Where care plans did contain information about how people wanted to receive their care and support this was not always followed.

People were not always supported to remain active and lead meaningful lives. Activities in the service were limited. A new activities co-ordinator had been recruited who was developing this aspect of care. We have made a recommendation about developing relationships between care staff and developing a community environment within the service.

The service had a quality assurance system in place which was used to identify shortfalls. However, this was not always effective and was not consistently used to drive improvement.

People did not feel there were sufficient staff to meet their needs. This was reflected in comments by people about how much time staff had to interact with them and build relationships. The service was addressing this and was recruiting more staff and developing a stable staffing team.

Staff received regular support and training. They knew how to minimise risks and provide people with safe care. Procedures were in place which safeguarded the people who used the service from the potential risk of abuse.

People were supported to make day to day decisions and interactions we observed were caring, but some people did not always feel the service was caring toward them; we have made a recommendation regarding developing relationships between care staff and developing a community environment within the service.

You can see what action we told the provider to take at the back of the full version of the report

Is the service safe?

We found that risk assessments to keep people safe when moving and handling people were detailed and contained all the information needed for staff to follow, detailing equipment to use and therefore keeping all concerned safe. We observed good practice in using the hoist on two occasions.

In the case of one person we concluded that their needs may not have been adequately assessed or suitable equipment provided, which meant that care and treatment was not planned and delivered in line with their individual care plan. A pressure sore had developed that could have been preventable. In the case of a second person we found that the nursing intervention was working and this person's skin was healing from a pressure sore. Therefore we concluded that the service was not consistent in keeping people safe from developing sore skin.

We examined the medication systems in use and found that these protected people as they were being followed and staff were trained to use them.

There have been no applications made under the Mental Capacity Act (MCA) 2005 in relation to a Deprivation of Liberty Safeguards (DoLS).We saw that there was a policy and procedure in place and that staff had received training. However we saw evidence that three people may be being deprived of their liberty unlawfully and requested this be explored and appropriately referred. This demonstrated that staff at the service were unaware of the legislation and may not know how to protect people and uphold their rights by appropriately using this legislation.

Is the service effective?

Care at St Fillians was effective because we saw systems in place to listen to people that used the service, their relatives and staff. We believe there was an open culture of listening to people. There were some systems in place to audit medication, care plans and infections control. To make this more effective the organisation should consider systems to capture and analyse other risks relating to falls and infections.

There was an effective roll out of training for staff with regular updates and high uptake in professional qualifications for care staff. There was evidence to show that staff were regularly supported in their role through meetings and supervision.

We found that the food was of good quality and well presented.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People using the service told us staff were caring. One person told us, 'I like the staff that look after me'. A relative said that they felt their family member was well cared for and that the staff were kind and thoughtful.

Two different relatives told us that they had been involved in their relatives care plan and were confident they knew what was written down on how best to care for their relative.

Is the service responsive?

We found evidence from people using the service, relatives and documentation that showed the service had not been responsive to people's needs with regards to personal care and support to eat meals. There had been occasions when the service had run with gaps in staffing. One relative said, 'There is not always enough staff'.

The service had a complaints procedure and whistle blowing procedure in place. Complaints had been raised and we saw evidence that the procedure was working as matters were investigated and generally put right to people's satisfaction. We left one matter with the managers to follow up that was brought to our attention during the inspection. People's experience and care records showed that they had access to a whole range of health professionals. This included seeking support and guidance from health care professionals, including falls prevention specialists. We met a professional at the service who was advising on pain control at the end of a person's life. They confirmed that the service had responded and referred people to them appropriately.

Is the service well-led?

The service did not have a registered manager in place, but steps had been taken to appoint a suitable person and in the meantime appropriate arrangements were in place to support the service with a temporary manager in situ. The service worked well with other agencies and services such as health and social care professionals to make sure people received their care in a joined up way.

The service had quality assurance systems, audits and records seen by us that showed identified shortfalls were addressed promptly. As a result the quality of the service was continuingly striving to improve.

We found that there was sufficient staff employed and on duty that were appropriately trained to meet peoples needs. We found care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We found that timely referrals were made to other agencies to maintain the welfare and health of people at the service.

A new manager has been appointed and we await their application to become registered.