This unannounced inspection was carried out on 14 October 2015. St Georges Nursing Home provides nursing care for people who are living with dementia and is registered to accommodate up to 63 people. On the day of our inspection 57 people lived at the service. The accommodation is arranged over two units over one floor. One of the units is for people with more complex needs and who may have behaviour that may challenge.
There was a registered manager in place who was present on the day of the 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. We were also assisted by the regional manager.
There were not always enough staff deployed in the service to consistently meet people’s needs. People sometimes waited long periods of time before they received support from staff. There were times where there were less than the required staff needed to care for people safely. There were no assurances that before staff started work appropriate recruitment checks had been undertaken. There were gaps in staff records and appropriate references or checks had not always been obtained.
Risk assessments did not always detail the support people needed. There was a lack of information for staff on some of the identified risks. We found that the environment was not always safe. Some furniture was arranged in way that was difficult for people to manoeuvre. Other risks had been assessed and guidance provided to staff on how to reduce them which included the risk of pressure sores and choking. There had been accidents and incidents recorded but there was a lack of analysis of what the registered manager had done to reduce the risk of falls and incidents in the service.
People’s rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had not always been completed specific to the decision that needed to be made around people’s capacity. DoLS applications had been submitted to the local authority. Other staff did have an understanding of MCAs and DoLS and were able to explain to us the reasons why assessments were undertaken.
People were not always receiving care from staff who had received appropriate training. There was a risk that people were receiving care from staff as they were not always kept up to date with the mandatory training including dementia and health and safety training. Nursing staff were not up to date with their clinical training.
Staff were not always supported in their work and said that they did not have regular supervision with their manager. They said “I don’t know whether I’m doing well or not.” There were over 60 staff who had not had a supervision with their manager this year. There was no opportunity for staff and their manager to discuss their performance or any ongoing training needs.
The environment did not always meet the needs of the people that were living there, particularly those who were living with dementia. There were very few destination points or signage to help orientate people around the service and assist with their independence.
Staff at the service were not always caring. There were times during the inspection where staff were not as supportive as they could be. People were ignored for periods of time throughout the day and on occasions staff chatted amongst each other and did not interact with people especially during the meal time. We did see times when staff were caring and considerate to people. People were complimentary about the staff. One person said “The carers are very good, they are kind”
People felt safe and staff had good knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. There were clear policies in place to guide staff should they have any concerns. Medicines were stored appropriately and audits of all medicines took place. Medicines Administrations Records (MARs) charts for people were signed for appropriately and all medicine was administered, stored and disposed of safely by staff who were trained to do so.
People’s preferences were not consistently being met. One relative told us that they were involved in their family members care and were contacted about any changes that had occurred. Staff at the service had the details of an advocacy service where people needed the support. The service was not always responsive to people’s needs. There was information missing in people’s care plans around support they needed. One person had been in hospital after having a significant injury but their care plan which had been updated didn’t reflect their current needs. Communication was not always shared with staff about people which put people at risk. The registered manager confirmed this and said that they were working on ways to improve the communication and sharing of information with staff.
There were not enough meaningful activities on offer specific to the needs of people living at the service. There were long periods of time where people had no meaningful engagement with staff. One person said to us “Sometimes it gets a bit boring but I do enjoy the exercises” whilst we heard another person say “I think I will go to bed, this is boring.”
Although people, relatives and staff felt that the registered manager was likeable, many of them reported that management was ineffective. There was not always consistent and obvious leadership in the service and staff said they didn’t always feel supported or valued. Not all staff received annual appraisals to discuss their performance or training and development needs. However some staff told us that the manager’s door was always open and felt that they could go to see them whenever they wanted. One told us “He (the manager) is always very visible and checks everyone is ok, his door is always open.”
There were not effective systems in place to assess and monitor the quality of the service. Audits and surveys had been undertaken with people, relatives and staff but had not always been used to improve the quality of care for people. Records were not always completed accurately and were not always complete. Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had not informed the CQC of significant events in a timely way.
There were times where staff responded appropriately to people’s care. One relative told us “I feel the home is outstanding and the nurses are excellent.” They told us that the staff had responded quickly to their family members’ ill health and felt that the family member would not be alive today without their intervention.
In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe. Where people needed to have their food and fluid recorded this was being done appropriately by staff. Intake and output of food and fluid was recorded on forms that were kept in people’s rooms.
Nutritional assessments were carried out when people moved into the home which identified if people had specialist dietary needs.
People had access to a range of health care professionals, such as the GP, dietician, Parkinson’s nurse and chiropodist. One health care professional told us that staff at the service regularly had contact with the local mental health team.
There was a complaints procedure in place for people to access. The registered manager told us that since taking up post they had not received a single complaint.
The overall rating for this report is ‘Inadequate’. This means that it has been placed into ‘Special measures by CQC. The purpose of special measures is to;
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement power in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.
Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such as there remains a rating of inadequate for any key questions overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the providers registration.
During the inspection we found several breaches 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.