This inspection took place on 15, 16 and 19 January 2018 and was unannounced. The home provides accommodation for up to 38 people with nursing care needs. There were 32 people living at the home when we visited, some of whom were living with dementia. All areas of the home were accessible via a lift and there were three lounge/dining rooms spread across both floors. There was accessible outdoor space from the ground floor. Bedrooms were a mix between single and shared occupancy.St John’s Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
There was a registered manager at the home. 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 December 2016, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to send us an action plan detailing how they would make improvements in the areas of: ensuring the service obtained appropriate consent to provide people’s care, and ensuring there were sufficient numbers of trained and qualified staff in place. At this inspection we found the provider was still not meeting the requirements of these regulations and we also found concerns in other areas.
There was no clear management structure in place. The provider did not have management or supervisory staff in place who were able to assume roles in overseeing the quality and safety of the service. As a consequence, there were deficiencies in key areas of the running of the service, which resulted in the compromised safety and wellbeing of people. The registered manager had worked hard in their role to make improvements, but told us they often did not have the resources to fully implement or imbed improvements.
People’s medicines were not managed safely. The medicines management system in place did not ensure effective, ordering, storage, administration, recording or disposal of people’s medicines. This put people at risk of harm as there were examples where people received the incorrect medicines or it was not clear which medicines they were prescribed to receive.
Risks to people’s individual safety were not managed effectively to reduce the risk of harm. Systems and plans to protect people in the event of an emergency were either not completed or did not fully consider the most effective action to take in order to keep people safe. Where risks had been identified around people’s health conditions, monitoring and management plans were put in place in order to manage these conditions. However, the actions and recordings related to these plans were not always clearly followed, which resulted in confusion about the support people had received and how effective treatment plans were. There were ongoing safeguarding concerns in relation to people’s health and wellbeing which the registered manager was investigating at the time of inspection.
There were enough staff working in the home, but staffing levels were maintained only with the addition of agency staff. The registered manager told us they were in the process of recruiting staff, but the service had experienced a high turnaround of staff leaving since our last inspection. Staff’s ongoing training and development needs were not closely monitored. Many staff required training updates to ensure their knowledge was current and following best practice.
People did not always receive personalised care. Care plans did not contain sufficient detail to enable staff to understand people’s behavioural and communication needs. Handover information between staff was not always sufficiently accurate to ensure that staff had all the information required to meet people’s needs. Guidance for some people was not clear about the support they required when eating and drinking. This resulted in confusion within the staff team about the appropriate levels of support people required. People had access to healthcare services, but documentation did not always make it clear about the healthcare interventions which people required in order to promote healthier lives.
Staff did not always follow legislation to ensure they complied with legal requirements where people lacked capacity to consent to their care. Where people were unable to make specific decisions about their care and treatment, staff did not follow best practice guidance to ensure that the decisions were proportionate and in people’s best interests. The registered manager had not fully assessed or taken steps to ensure that people’s accommodation arrangements were fully supportive of their rights and freedoms. The registered manager did not always inform CQC when people had authorisations granted in relation to their accommodation when they lacked the capacity to consent to care arrangements. This was a statutory requirement.
The system of audits and quality assurance were not effective in monitoring the quality and safety of the service. Audits were completed, but they did not identify where issues around medicines or emergency equipment needed remedial action.
People were not always treated with dignity and respect. There were examples where staff not fully respectful of people’s wishes or right to privacy. People told us there was a distinction in the quality of staff between permanent and non-permanent staff, who were not always familiar with their needs. People said they were consulted about their care, but staff could take a long time to action requests.
The registered manager sought feedback from people about the service and dealt with complaints in an open and consistent way. Team meetings were used as a platform to discuss issues and make improvements, but they were not always effective in proving a catalyst to positive change.
The service was clean and there were systems in place to reduce the spread of infections. The provider had made adaptations to the building to make it suitable for people and specialist equipment was in place to support people around their health and mobility. There was a programme of activities in place, which people spoke positively about.
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.”
We identified seven breaches in six regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009.
You can see what action we told the provider to take at the back of the full version of the report.