St Andrews 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.

St Andrews Care Home provides care and support to up to 70 people some of who live with dementia. At the time of our inspection there were 58 people being supported by the service.

At our last inspection on 24 February 2016 we rated the service good. At this unannounced inspection on 03, 11, 17 and 19 October 2018 we found evidence from our inspection that demonstrated risks to people’s safety and wellbeing. This was in relation to keeping people safe from harm, managing people’s medicines safely and monitoring the quality of care provided. The overall rating of the service has changed since our last inspection to ‘Requires Improvement.’

The service had a registered manager in post. 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.

People felt safe at the service. Staff had received relevant training on how to safeguard people but not all staff understood their responsibilities to report concerns. Medicines were stored appropriately but people on one unit did not receive these as the prescriber intended. Lessons from previous incidents were not consistently reviewed to improve the quality of care.

Risks to people’s safety and well-being were identified and managed to keep them safe from harm. Assessments were in place that gave guidance to staff on how individual risks to people could be reduced. Relevant pre-employment checks had been completed for all staff and safe recruitment practices followed. People were supported by sufficient numbers of staff. People lived in a clean and well-maintained environment.

Staff had attended relevant training to their role and spoke positively about the training they were provided, however training had not always been effectively delivered. Staff felt supported, although not all staff had regular supervisions and appraisals.

People’s consent was obtained, and staff were aware of how to support those people who may not be able to provide their consent. However, these decisions were not all documented as required. This was an area under review by the registered manager. People’s nutritional needs were met and the deputy manager was reviewing how people were provided with additional nutritional snacks.

People told us that staff were friendly and respected and promoted their privacy and dignity. Staff knew people well and were knowledgeable about people’s individual needs. People felt staff knew what was important to them and how people chose to spend their day.

People’s individual needs were assessed and people or where appropriate, their relatives were involved in the planning of how their support would be delivered. Care and support plans were regularly reviewed to ensure that they met people's current needs. However, people’s care records were not always updated to reflect their preferences or choices.

People were encouraged to provide feedback on the service they received and knew how to make a complaint. Quality assurance systems were in place, but not always effectively managed such as audits of medicines and peoples records. Audits carried out by the registered manager and provider did not identify some of the areas for improvement found at this inspection. People’s views and opinions were sought about the running of the home and care provided. Staff were encouraged to attend and take part in team meetings which were held regularly. Notifications of significant events were made when the registered manager was made aware of the incident by s

The inspection took place on 24 February 2016 and was unannounced. The inspection team consisted of three inspectors due to the size of the home. The service is registered for 70 people and on the day of our inspection there were 67 people living at the home.

There was a manager in post who had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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.

People and their relatives told us that their family members were well cared for and they were happy with the standards of care and support their relatives received. There were no odours in the home and people looked well groomed. Bedrooms were personalised and it was obvious people could have their personal items around them and had a choice of where to spend their time and what activities or hobbies they wished to participate in.

People told us they felt safe living at St Andrews. Staff had received training in how to safeguard people from potential abuse and knew how to report concerns. Safe and effective recruitment practices were in place and this helped to ensure that staff were suitable to work in a care home environment. In most cases there were sufficient numbers of staff available to meet people’s agreed care needs when required. However on the day of our inspection we observed that on one unit in particular the staffing levels were not adequate to meet people’s needs in a timely way.

Staff were trained to assist people with taking their medicines regularly and safely. Potential risks to people’s health and well-being were assessed and where risks had been identified, remedial actions to reduce risks were put in place and these were reviewed regularly to help keep people safe.

People and their relatives and healthcare professionals were very positive about the standards of care in the home. They were complimentary about the staff and their experience, skills and abilities to support people appropriately. Staff were well supported and received training relevant to their roles and responsibilities. They had regular supervision with their line manager to discuss and review their performance and any development needs.

People had developed positive and caring relationships with the staff who supported them. Care and support was provided in a way that took account of their individual needs and preferences and the management team and staff knew people very well.

Staff were observed to obtain people’s consent before providing care and support to them. People, and where possible, their relatives were involved in the planning, delivery and review of the care and support provided. Information held about people’s medical and personal histories was securely maintained throughout the service and was only accessed by people who had a right to access it and where the people concerned had consented to the sharing of their personal information.

People told us that their support was provided in a way that promoted their dignity and respected and maintained their privacy. People were supported to take part in activities that interested them, both at home and in the local community. People felt that staff listened to them and responded to any concerns they had in a positive way. They knew how to complain if they needed to, however none of the people we spoke to during our inspection had ever had to make a complaint.

People and their relatives were positive and complimentary about the way the service operated including the management team and staff approach. There were effective arrangements in place to monitor risks and the quality of services provided. Systems and processes were used in a way that encouraged continual improvements to the quality of the service.

We inspected this home in January 2014 and in June 2014 and we found that they were not meeting the standards in relation to the care and welfare of people, nutrition, co-operating with other providers, management of medication, and assessing and monitoring the quality of service. On our visit of the 21 July 2014 we found the home compliant in all areas we had inspected.

Is the service caring?

We spoke with eleven people who used the service and they all told us that the staff were caring and that they were well looked after. We heard staff speaking with people in a kind and gentle manner and we saw that they made good eye contact with the person and we saw that staff offered comfort to people who were upset.

A regular visitor to the home told us that the people who used the service were, “Treated very well.” They also said that, “The care here is better and the staff are lovely."

A person who used the service said, "It's very good here, we get very spoiled and they are very helpful."

Is the service responsive?

A health professional who worked closely with the staff told us that they felt the care provided was appropriate to meet people's needs. They said that the communication with staff was clear and that they were responsive to instruction.

The activity provision at St Andrews has been designed to meet individual’s needs and preferences. People told us that their call bells were answered promptly and that the staff will get to them what needed.

Is the service safe?

People told us that they felt safe at all times. We found that medicines were stored safely for the protection of people who used the service and that people were receiving their medicines as prescribed by their doctor.

We found that regular audits of records were undertaken to ensure that care plans and risk assessments were up to date. Staff training and development needs were reviewed frequently so that people were cared for by appropriately skilled and experienced staff.

We noted that there were detailed risk assessments in place including fire safety, infection control and first aid in order to minimise the risk of injury to people using the service and staff.

Is the service effective?

We saw that, where people did not have the capacity to make their own decisions, family members and advocates had been involved and appropriate referrals had been made to safeguard the person. We found that the provider had systems in place to ensure people's consent was obtained before care or support was provided, and the provider acted in accordance with people's wishes. When the home was no longer able to meet the person’s needs the appropriate professional health and social care staff were involved to ensure the person’s welfare.

Care and support was planned and delivered in a way that was intended to ensure people's safety and welfare.

Is the service well led?

A relative told us that the manager was always responsive to any concerns they raised.

We saw evidence to confirm that a provider’s representative visited the service monthly and completed a report of their audit. The manager told us the report was made available to them immediately so actions could be carried out promptly.

We carried out this inspection to look at the quality of service people with dementia experienced. In addition, this inspection was to follow up on previous non-compliance where the service had shortcomings. This was in regard to recording and monitoring a person's weight, the cleanliness of the environment and poor management of medicines.

We found that the service had made improvements in relation to the cleanliness of the environment. We reviewed their management of medicines and although improvements had been made in regards to the issues found at our previous visit, there were other issues regarding obtaining of appropriate quantities of medicines.

The inspection identified that the service still needed to make improvements regarding the recording and monitoring of people's weight.

For the dementia themed inspection we pathway tracked five people's care, spoke with people, their relatives and staff. We also provided comment boxes to help obtain people's views. We found that staff had been given sufficient training to understand the experiences of people living with dementia, but the person centred approach was not always practised. Staff told us this was due to there not being time to provide it.

We saw from records that people had appropriate access to other professionals, including health and social care support. The service was proactive in assessing a persons' health and contacting the relevant medical professional.

Although the service had systems in place to assess and monitor the quality of the care provided to people living with dementia, we found that these were not well managed or effective.

We spoke with 14 of the 67 people who lived at the home at the time of our inspection. People told us that the care workers always knocked on their door before entering the room and asked for their consent before any care was delivered. People also told us that they were very happy with the care that they received. One person told us: "I don't think there is a better home in the whole of the area."

We looked at the care records of 10 people who lived at the home. We noted that people had not always received the care that they had been identified as needing. We also noted that detailed assessments of the possible risks to people had not always been completed or fully updated.

We saw that in each care record there was a partially completed form that would be completed and passed to another service in the event of the person being transferred. This document detailed the personal information required by the receiving service.

On the day of our inspection the home looked clean and bright. However, on one unit there was a very unpleasant odour and we found other areas where the required standard of cleanliness was not met.

We found discrepancies between the medication held and the record of the medication administered for one person and that medication had been stored for periods at temperatures in excess of the maximum recommended.

We saw that there was an effective system to regularly assess and monitor the quality of service that people received.

We inspected St Andrews Care Home on 26 July 2012 and spoke with 16 people who live there. We also observed five people in their dementia unit being supported by staff and eight people in the residential unit during their lunch. All people spoken with stated that they felt supported and respected. One person told us: “This is an excellent home. Staff are very good. They listen to what we say and help us when we need help. There are enough staff generally, but sometimes it feels like there are not enough. Staff are good, but don’t have much time to stop and just sit and talk to us”.

Another person in another unit told us that that there were enough staff on duty. They also thought that, “Sometimes another member of staff would help, maybe they would then be able to stop. They are really hard working and know how to help us.”

Eight people around the table at lunch time told us that they have one cooked meal or a salad. Four of them stated that they liked the salad and were pleased with it being available. One person stated that they could ask for an alternative and another said that he did not know about this option.

We observed people at lunch time. A trolley with food was brought into the dining room allowing people to see options and make a choice between the prepared meal and salad. Staff asked everyone if they wanted the meal from the menu.

People told us that they could go wherever they want within the home. We observed people walking and being supported by staff and three people supported by their relatives walking freely through their units.

We saw a staff member offering a snack and one person chose porridge at midday. The staff prepared them a bowl and sat with them to help them eat.

All people we asked confirmed that they were happy for staff to hold and administer their medication.

We observed a staff member giving people their medication in one unit. People patiently waited their turn. Everyone had got a clean glass of water to take their medication. One person chose to take their medication with juice and another staff member prepared them a drink.

Family members with whom we spoke said they felt confident that their relatives were safe living in St Andrews Care Home.

People living in the home with whom we spoke told us that they felt they were respected and attended to very well.

A relative told us “I am very happy with the home. Generally I think the care is excellent, the food is fabulous and the cleanliness is beyond my expectations.”

A person living in the home told us “On the whole it’s quite good; there are always things to do if you want to.” Another person said “We have a book club, it’s really fun and we have seated keep fit on Monday morning, it’s very good.” A person told us “They brought in some Owls last week, they flew around the lounge and one came and landed on a leather glove I was wearing, it was marvellous!”

A relative with whom we spoke said “I believe absolutely that the staff really do have the right competencies and skills to look after my relative safely and caringly.”

During this inspection we set out to answer our five questions; is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, discussions with people who used the service their relatives, the staff who supported them and from looking at records.

We found that the home was not meeting the outcomes we inspected.

If you wish to see the evidence supporting our summary please read the full report.

You can see our judgements on the front page of this report.

Is the service caring?

We found that some of the staff we observed delivering care were kind and caring. We saw from our observations that while some staff delivered care in a person centred manner others did not. By person centred we mean that staff focused on the person rather than on the task they needed to complete. We saw that there was a lack of respect for the privacy and dignity of the person. We saw that some of the staff looked to their own needs without exploring the effects of this on the people.

Is the service responsive?

We saw that people’s needs to be comforted and stimulated were not met. People were left unattended at lunch time. We saw throughout the day that staff assisted people in a manner that did not promote their personhood and dignity. We saw a senior staff member assist a person with their mobility by leading them by the hand in a childlike manner. The staff member set the pace, making the person move faster than they appeared comfortable with.

Staff consistently told us that they did not have time to spend with people other than to meet their immediate needs.

Is the service safe?

We were told that the systems in place to ensure the welfare of the people were not always followed by staff. This meant that the manager of the home was unaware of the risks that this may have been posed to some of the people.

Is the service effective?

We saw from our observations on the Windsor Unit that the home did not have effective processes in place to ensure the welfare of the people. On the day of our inspection we noted that people’s lunchtime medicines were not administered until late afternoon.

Is the service well led?

We identified that the home had not met required standards on the care and welfare of people at our inspection in August 2013. The provider sent us an action plan as to how these requirements would be met in November 2013. This stated that the requirements would be met by November 2013. We inspected again on 29 January 2014 to see if the improvements had been made. We identified that the standards for the care and welfare of the people, meeting nutritional needs and the administration of medicines had not been met.

The area of the home this inspection was mainly focused on had one member of the management team based there. We saw that although they were there throughout the inspection they had no impact on the quality of care provided to the people.

During our inspection we identified areas of concern that were very apparent. The staff on duty and the management staff on the floor had not identified or acted on these areas of concern.