Archived: St Clements Nursing Home

St Clements Nursing Home is a residential care home providing personal and nursing care to 13 people aged 65 and over at the time of the inspection. The service can support up to 37 people.

St Clements Nursing Home accommodates 37 people in one adapted building with three floors however only two floors were in use at the time of the inspection.

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

Improvements had been made to the quality and safety of the service since the last inspection. We identified a continued breach in relation to governance because these improvements were not yet embedded and sustained. We identified some record keeping issues and systems to oversee the safety of the service were not all robust.

People told us, and we saw the home was clean. We saw some improvements were required to ensure consistently good infection control practice. People and relatives told us they felt the service, and the support people received, was safe. Staff had received safeguarding training and knew how to escalate suspicions of abuse. However, systems to safely monitor some people’s monies were not robust. Staff knew about people’s risks and how to help promote people’s safety and health.

We saw improvements to how people’s risks were managed including support with medicines, and how incidents were responded to. Further improvements were being embedded. We found the breach of regulation identified at our last inspection had been met.

We saw, and relatives told us people received support when they needed it, however people’s feedback suggested this was not consistent. Further improvements needed to the provider’s recruitment processes were underway.

We saw improved support from staff who knew how to meet most people’s needs well, however improvements were required to achieve consistently good support, for example for people’s needs associated with mental health and dementia. Staff described improved support and development opportunities and training updates were underway.

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; although the policies and systems in the service did not always support this practice.

People received good support with meals and drinks but gave mixed feedback about the quality of meals provided. People were supported to access healthcare support. Improvements had been made to the design and décor within the floor of the home that was in use at the time of the inspection.

We saw, and relatives told us people were involved in aspects of their care however people’s feedback suggested this was not consistent. Staff took opportunities to speak with people and had a caring, friendly approach. People told us they were treated with dignity and respect. We found the breach of regulation identified at our last inspection had been met.

People and relatives described support that met people’s needs and we saw staff followed people’s preferences. However, care planning processes did not ensure all people’s needs were known and met as far as possible, including access to activities. Records were regularly reviewed but not always sufficiently detailed. Further improvements were planned.

People, relatives and staff all described a positive and improved culture. Staff felt involved in improvements at the service and told us they felt supported by the new management. Audits had helped identify further areas of improvement required to the quality of the service and people’s experiences.

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 February 2019).

Enforcement (and update)

After our last inspection, we carried out enforcement action to impose conditions on the provider’s registration. The conditions required the provider to submit monthly reports to the Commission in relation to their quality assurance activities, and to seek approval from the Commission prior to any admissions to St Clements Nursing Home.

At this inspection we found improvements had been made and the provider had met all but one of the breaches identified at the last inspection. We found the provider was still in breach of one regulation related to governance because improvements to the quality and safety of the service need to be embedded and sustained. We therefore decided that the condition requiring the provider to submit monthly reports to the Commission in relation to their quality assurance activities, will remain imposed on the provider’s registration to support continued improvements.

This service has been in Special Measures since February 2019. 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 and was to follow up on action we told the provider to take at the last inspection. The overall rating for the service has changed from Inadequate to Requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to continue to make improvements. Please see the full report for more information.

You can see what action we have asked the provider to take at the end of this full report.

At the last inspection we recognised the provider had failed to always notify the Commission as required. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme and through the remaining condition imposed on the provider’s registration. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

However, at this inspection on 17 December 2018, we found the provider had failed to sustain and build on improvements and the service had deteriorated. 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 found the provider had breached four regulations of the Health and Social Care Act 2008 which relate to good governance, safe care and treatment, dignity and respect, and person-centred care. We found the provider had also failed to inform the Commission of specific events and incidents as required by law. We will report on action we have taken when it is completed at the back of the report.

St Clements Nursing Home is a care home which provides nursing and personal care for up to 37 older people. 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. The home has accommodation over two floors with a passenger lift to facilitate access. There were 23 people living at the home at the time of our inspection.

There was a new manager at the home who had joined in November 2018 and had submitted their application to register with the Commission. The manager was present during our 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 identified a breach of the regulations because people’s risks were not all safely managed, including poor support some people received with their medicines and bedrail use which placed them at risk of harm. Although people and relatives told us they felt safe, systems were not robust to ensure people could always be safeguarded from the risk of abuse. There were not always enough staff to meet people’s needs.

Communal areas of the home were kept clean by domestic staff although we detected odours and infection control concerns in some areas of the home. Systems did not ensure the consistent safety of the premises.

People’s needs were not always understood and effectively responded to by staff. Staff had not received the training and guidance required for their roles and improvements were still required to how people were supported with their meals. The design and décor of the home were not always developed around people’s needs. People were supported to make their own choices and decisions.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

We last inspected this service in July 2016 and found that the provider was breaching seven of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We had found that the provider had failed to ensure that tasks and activities were reflective of people’s individual needs and preferences. People were at risk of harm through unsafe care practices and poor medicine management. People were also at risk of not receiving food and drink which met their specific needs. Systems to monitor the quality and effectiveness of the service including complaints were not robust. Staff were not always suitably deployed to prioritise and meet people’s immediate care needs. After the inspection the provider sent us an action plan of how they were going to address our concerns.

At this inspection we found that improvements had been made however further action was required to ensure improvements would become embedded in the service’s culture and staff practices. Staff did not always have regard to how their tasks were impacting on the people around them. Although measures had been introduced to ensure confidential information about people was not shared in public on occasion we could overhear staff discuss the people they were supporting. People received food and drink in accordance with their needs and preferences however people did not always enjoy a pleasant meal time experience. Systems to ensure people received their medication appropriately had improved but recording sheets had not always been completed consistently.

The registered manager had stopped working at the service in October 2016. We were accompanied during this inspection by the new manager who had worked at the service since November 2016 and was in the process of applying to become the 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The manager had assessed people’s conditions in order to identify any specific risks and how they could be reduced. Staff knew how to identify and take action when they thought people were at risk of abuse or harm. Although there were enough staff to support people promptly individual staff were having to support several people at once during busy times in order to minimise any risks of harm.

Although people gave us mixed views about the quality of their meals we saw that people were offered a choice of food which reflected their preferences. People’s meals were often interrupted by staff carrying out tasks. People were supported to make their own choices and decisions although staff did not always ask people if they were being supported in line with their wishes.

People told us they felt their health needs were met and we saw that when necessary staff worked with other health care professionals to provide people with effective health care.

The manager had taken action to improve how people were supported to maintain their dignity. People said staff treated them with respect. People and their relatives were invited to be involved in planning their care and how the service was run.

People’s rooms were personalised in accordance with their preferences but there was little organised activity for people in communal areas. The manager was taking action to improve how people were supported to take part in activities they enjoyed.

People living in the home and relatives told us that they felt the home had improved. The manager had reviewed and developed clear policies and procedures for dealing with complaints. Systems to monitor the quality of the service including complaints had been improved and the manager had developed and was adhering to a service improvement plan. We noted that further action was required to ensure these improvements were embed in the service’s culture and consistently followed by staff.

St Clements is a residential home which provides nursing care to older people most of whom are living with dementia. The service is registered with the Commission to provide accommodation and personal care with nursing for up to 37 people and at the time of our inspection there were 29 people using the service. There was a registered manager at this location. 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 and associated Regulations about how the service is run.

The registered manager had improved how they responded when they receive information of concern about a person’s safety and the provider had made adjustments to the environment to make it safer for the people who used the service. However they had failed to take effective action to ensure there were enough staff to so people were supported to live independent lives and had not developed robust systems to monitor the quality of care people received. We found additional concerns with how people were protected against the specific risk presented by their conditions and medication. People continued to experience a lack of person centred care and meaningful interaction with staff and activities. You can see what action we told the provider to take at the back of the full version of the report.

Although the registered manager had reviewed the complaints process some people still did not receive a prompt or full response to their concerns.

The provider had taken action to improve the standard and safety of the environment. However some maintenance work was ineffective and was not always conducted in consideration of the needs of the people who used the service.

How staff protected people from risks did not always reflect recent advice from other health care providers. People were not always supported in line with their care plans.

Medication was not managed safely. Some medication was not stored at the correct temperature to maintain its effectiveness and there was a risk that some people’s medication would run out before additional stocks were available.

Meal times continued to be a task orientated activity and did not promote people’s independence or enjoyment. People receive sufficient nutrition to meet their needs although the provider had taken no action to promote people’s independence. Snacks and drinks were not freely available outside of set times.

People who used the service had mixed views about how good it was but relatives spoke positively about the care people received. People were able to comment on the care they received and were supported in line with the Mental Capacity Act 2005.

Activities continued to be group orientated and did not reflect the interests and abilities of people who used the service. Activities did not promote people’s independence or consider how they might help with the management and improvement of some people’s specific conditions.

Systems to monitor the quality of the service had failed to identify that effective action had not been taken to address known concerns about the service.

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 spoke with 10 people that lived there and observed how other people were supported by staff. We spoke with four relatives, the registered manager and the deputy manager. We also spoke with three care staff on duty and the maintenance person. Our conversations with people helped us to answer our five questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? and, Is the service well led?

Below is a summary of what we found. The summary is based on our findings during the inspection.

The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

All of the people and their relatives spoken with told us that they felt that the care provided was safe. A person living at the home told us, 'At the moment they are caring for me and no one has troubled me so far, so I feel safe.'

We saw that people's care was planned and any risks associated with providing the care was assessed and managed appropriately.

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

We saw that the environment within the home was maintained to ensure that people lived in a suitable safe home. We saw that equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.

Recruitment records that we looked at were in line with the requirements of the regulations. Where there had been an issue about staff conduct the provider had taken appropriate action that ensured that people were safe.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. We saw that where it was necessary the home followed appropriate procedures under these safeguards to ensure that people's rights were protected and they were safe.

Is the service effective?

All of the people and their relatives spoken with told us that they were receiving the care that they needed.

We saw that the home sent a regular newsletter to relatives so that they were kept informed about things happening in the home.

Care plans were detailed and kept under regular review, so that staff had up to date information on how to care for people.

Health information was detailed so that staff had the information they needed to support people safely.

We saw that where people required equipment to support their care this was available and maintained to ensure that they were suitable.

Is the service caring?

All of the people and their relatives spoken with told us that they felt that the service was caring. A relative told us, 'They are always sociable and the staff are caring. Mom is happy here.'

We walked around the home and watched to see how staff treated people. We saw good interactions between people and staff. We saw that staff were friendly and laughing and joking with people as they offered support. We saw that people were supported by staff in a sensitive and respectful way. A person living at the home told us, 'I think they are caring. They always ask if you are alright and if there is anything they can do.'

We saw that people were dressed in clothing appropriate to their age, gender and the weather. We saw that everyone living at the home looked well groomed.

Is the service responsive?

All the people and their relatives that we spoke with told us that they had no concerns or complaints about the care provided. A relative told us, 'I have no worries about mom being here. I know if there is a problem they would ring me.'

We saw that where people were cared for in bed or were sitting in their rooms call bells were in easy reach, so they could call for help if needed. One person living at the home told us, 'I ring the bell if I need them and they do come.'

We saw from care records looked at that the home involved other professionals in supporting people's care as required. People were able to practice their faith and religious beliefs and care plans were designed to ensure that people's diverse needs were recorded and catered for.

We didn't see any activities taking place in the home, on the day of our inspection. However, we understand that there were plans in place to demonstrate that people were involved in meaningful activities that were important to them.

We saw relatives freely visiting the home whilst we were there, so people could maintain relationships with family and friends.

Is the service well led?

All the people and their relatives that we spoke with had no concerns about the service. Systems were in place to monitor the quality of the service. Where people had raised concerns we saw that these were investigated and resolved.

We saw that the home had a staffing structure that enabled the service to be managed appropriately. This included a manager that was registered with us and was responsible for the running of the service. We saw that there was a good atmosphere in the home. People were consulted about the quality of service they received. We saw that comments and concerns were analysed and improvements were put in place where they had been identified. All staff spoken with said they thought that the home was well managed. They said that staff meetings were held and they were able to put forward ideas for improvement in the home.

All the people living at the home that we spoke with said that staff talked to them about their care needs on a daily basis. We found that systems were in place to involve people and their relatives in giving consent to their care and treatment.

All the people that we spoke with told us that they were receiving the care that they needed. One person told us, 'Yes I am being looked after and they treat me alright.' We found that people experienced care, treatment and support that met their needs and protected their rights.

All the people that we spoke with told us that they felt safe living at the home. We saw that systems were in place to ensure that people living at the home was safeguarded from abuse.

All the people that we spoke with told us that they were treated well by the staff that supported them. We found that staff received the support they needed to do their job.

People who used the service did not live in premises that were suitable maintained to a good quality standard.

All the people that we spoke with said that they had no concerns about living at the home. One person told us, 'I am being looked after well and my family can visit any time.' We found that systems were in place to monitor the care that people received.

During this inspection we saw that systems had been put in place to ensure that people and their representatives were able to give their consent to their care. The management of medicines had improved and was being monitored. Some staff had received updated training. However the provider had not ensured sufficient improvements in staff training supervision and appraisal to demonstrate full compliance with the regulations.