St Bernards Residential Care Home Limited

Updated 11 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by 3 inspectors. Two inspectors visited the home and the third inspector gathered feedback from people’s relatives via the telephone.

Service and service type

St Bernards Residential Care Home Limited is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Bernard’s Residential Care Home Limited is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed the information we had received about the service since the last inspection, and we gathered feedback from local authority commissioners who work with the service. We used all this information to plan our inspection.

During the inspection

During the inspection we spoke with 7 people and 5 people’s relatives to gather their experiences of the service and to find out what it was like to live at the home. We observed the care and support provided to people in communal areas.

We spoke with 11 members of staff including the deputy manager, the receptionist, team leaders, care assistants, a laundry assistant, the compliance manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed seven people's care records and multiple people's medication records. We looked at a range of records relating to the management of the service, staff training data, fire safety records, some policies and procedures and the recruitment records of three staff members to check they had been recruited safely. We shared our inspection findings with one local authority and our findings about fire safety with West Midlands Fire Service.

Updated 11 November 2022

About the service

St Bernards Residential Care Home Limited is a care home providing personal care to a maximum of 43 older people. At the time of our inspection 36 people lived at the home and one person was in hospital. Some people lived with dementia.

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

Managerial oversight of the service required improvement. Some of provider’s systems and processes to monitor the quality and safety of the service remained ineffective and had not identified the shortfalls we found. Policies and procedures were not always followed. The management team needed to increase their knowledge of some requirements to ensure all regulations were complied with.

Risk management required improvement. Information staff needed to help them provide safe care was not always available to them and timely action had not been taken to ensure all fire safety risks had been mitigated to keep people safe.

That meant opportunities to make improvements had been missed. Whilst people told us they received their medicines we found they were not consistently managed in line with the provider’s expectations or best practice guidance.

The provider understood their responsibility to be open and honest when things went wrong. Responsive remedial action was taken following our visit to make improvements which demonstrated lessons had been learned. Two weeks after our visit the nominated individual told us actions taken including strengthening auditing systems had improved safety.

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.

People felt happy and safe living at the home. The culture of the service was inclusive, and people felt listened to and involved in the running of their home. Relatives shared that viewpoint. Staff felt supported and appreciated and spoke highly of their managers. The nominated individual was proud of the staff.

Staff had been recruited safely and there was enough of them on duty to meet people's needs. The home was clean, and visitors were welcomed. Staff worked in partnership with health professionals which supported people's health and wellbeing.

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 good (published 21 June 2019).

At the inspection in 2019 we recommended the provider reviewed their quality assurance systems to ensure they were fully effective. The recommendation had not been acted up. We also recommended people's consent to their care and support was recorded. That had happened which meant improvement in that area had been made.

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.

We received concerns in relation to staffing levels and medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. 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 and well-led sections of this full report. The provider has taken action to mitigate the risks we identified.

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

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 safety and good governance. 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.