The inspection took place on 26 and 27 April 2017 and was an unannounced inspection. The home is registered to provide accommodation with personal care and nursing for 45 older people. At the time of our visit there were 39 people living at the home.

There was 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 home is run.

People and their relatives told us that they felt safe at the home. Staff were trained in adult safeguarding procedures and knew what to do if they considered someone was at risk of harm, or if they needed to report concerns.

There were systems in place to identify risks and protect people from harm. Risk assessments were in place and carried out by staff who were competent to do so. The risk assessments recorded what action staff should take if someone was at risk. Referrals were made to appropriate health care professionals to minimise risks and meet people’s health needs.

There were sufficient staff to keep people safe and meet their needs. The registered manager had followed safe recruitment procedures. Medicines were given to people on time and as prescribed.

Policies and procedures were in place to guide staff in relation to the Mental Capacity Act 2005. Staff understood the processes in place for ensuring decisions were made in people’s best interests. Staff and the registered manager were ensuring these steps were taken for people living at the home. Staff sought people’s consent and recorded this.

Staff were caring, they knew people well, and they supported people in a dignified and respectful way. Staff acknowledged and promoted people’s privacy. People felt that staff were understanding of their needs and they had positive working relationships with them.

People and their relatives were involved in the assessment and reviews of their needs. Staff had knowledge of people’s changing needs. They supported people to make decisions or changes to the way their planned care was delivered. Staff offered choices to people regarding all aspects of their care and support, and upheld these choices. People told us that they had access to activities and hobbies.

People and staff knew how to raise concerns and these were dealt with appropriately. The views of people, relatives, health and social care professionals were sought as part of the service’s quality assurance process. Quality assurance systems were in place to regularly review the quality of the service that was provided.

This was an unannounced inspection carried out on 20 September 2016.

St Andrew’s Nursing and Care Home can provide nursing care and personal care for 45 older people and people who live with dementia. There were 40 people living in the service at the time of our inspection.

There was a 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection of this service on 10 February 2016 when we found that there was a breach of a legal requirement. This was because the registered persons had not consistently completed robust checks to monitor and assure the quality of all the facilities and care provided in the service. This had resulted in shortfalls in the care and facilities provided for people not being quickly addressed.

After our inspection of 10 February 2016 the registered persons wrote to us to say what improvements they intended to make in order to meet the legal requirement in relation to the breach. They said that a series of new and more robust quality checks would be introduced to ensure that in future people consistently benefited from receiving all the care and facilities they needed and expected. They said that the necessary improvements would be completed by 22 March 2016.

This report only covers our findings in relation to the action taken by the registered persons to meet the breach of legal requirements. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Jasmine Healthcare Ltd on our website at www.cqc.org.uk

At this inspection, we found that the registered persons had introduced most of the quality checks that were necessary to ensure that people reliably received all of the care and facilities they needed. This meant that the breach of the legal requirement had been met. However, some further improvements were still needed. These included strengthening the way in which people were consulted about the development of the service. In addition, more steps needed to be taken to address some remaining defects in the accommodation.

This was an unannounced inspection carried out on 10 February 2016.

St Andrew’s Nursing and Care Home can provide nursing care and personal care for 45 older people and people who live with dementia. There were 42 people living in the service at the time of our inspection.

There was a 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 in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because quality checks had not been robust and this had led to a number of shortfalls not being identified and quickly addressed. You can see what action we told the registered person to take at the end of the full version of this report.

Some background checks had not always been completed before new staff were appointed. People had not consistently been protected from the risk of accidents and some of the arrangements used to promote good hygiene were not robust. Staff knew how to respond to any concerns that might arise so that people were kept safe from abuse. There were enough staff on duty and medicines were ordered, dispensed and disposed of safely.

Staff had received training and guidance and they knew how to care for people in the right way. This included being able to assist people to eat and drink enough in order to stay well. In addition, people had been supported to receive all of the healthcare assistance they needed.

The registered manager and staff were following the Mental Capacity Act 2005 (MCA). This measure is intended to ensure that people are supported to make decisions for themselves. When this is not possible the Act requires that decisions are taken in people’s best interests.

The Care Quality Commission is required by law to monitor how registered persons apply the Deprivation of Liberty Safeguards (DoLS) under the MCA and to report on what we find. These safeguards are designed to protect people where they are not able to make decisions for themselves and it is necessary to deprive them of their liberty in order to keep them safe. In relation to this, the registered manager had taken all of the necessary steps to ensure that people’s rights were protected.

People were treated with kindness and compassion. Staff recognised people’s right to privacy, promoted their dignity and respected confidential information.

People had received all of the care they needed including people who could become distressed and who needed reassurance. People had been consulted about the care they wanted to receive and they had been given all of the assistance they needed. Staff had supported people to express their individuality and most people were satisfied with the support they received to pursue their interests and hobbies. There was a system for resolving complaints.

People had been consulted about the development of the service. Staff were supported to speak out if they had any concerns because the service was run in an open and relaxed way. People had benefited from staff acting upon good practice guidance because it helped to ensure that they received care which reliably met their individual needs and wishes.

This summary is based on information we obtained when we visited the service on 05 November 2014. We completed this inspection to check that the provider had made the improvements that we said must be made when we inspected the service on 10 June 2014. At our earlier inspection we found that improvements needed to be made to the way in which people were supported to eat and drink enough. In addition, we said that improvements were needed to the way some people were assisted to avoid developing pressure ulcers.

We found that improvements also needed to be made to parts of the accommodation in order to provide people with a safe setting in which to receive care. This was because repairs needed to be made to the passenger lift. In addition, we noted that the provider had not made robust arrangements to reduce the risk of people being accidentally burnt by radiators that were not fitted with guards.

Furthermore, we found that there were shortfalls in some of the quality checks that had been completed.This was because they had not effectively identified and resolved the problems we had noted during the course of our inspection. In addition, the provider had not completed an up-to-date assessment of the fire safety system used in the service. This oversight had contributed to some routine fire safety checks not being completed. These mistakes had reduced the level of fire safety protection available in the service.

We said that all of the shortfalls in care delivery and accommodation needed to be addressed. This was necessary so that people could receive responsive care in a safe setting.

After our inspection dated 10 June 2014 the provider wrote to us and said that it had made the improvements that were necessary to address all of our concerns.

Our inspection dated 05 November 2014 examined the way in which people were supported to eat and drink enough and to keep their skin in a healthy condition. In addition, we looked at how people were protected from avoidable environmental hazards. Further, we established what steps had been taken to strengthen the way in which quality checks were completed.

We found that the provider had introduced all of the necessary improvements.

This inspection was completed by an inspector and an expert by experience. The expert by experience spent a considerable amount of time speaking with people who used the service and observing the care that was provided.

The summary is based on our observations during the inspection, speaking with 13 people who used the service, five relatives, the manager and four staff. In addition, we looked at care records, observed care being provided, reviewed parts of the health and safety system and examined the accommodation.

We considered our inspection's findings to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found:

Is the service caring?

People said that staff were respectful, kind and attentive. They considered staff to be genuinely committed to helping them. Relatives were confident that staff were polite and courteous to people who used the service. However, we witnessed two occasions on which people were not treated in ways that fully respected their rights to dignity and privacy.

Is the service responsive?

We saw that most people's individual needs for care had been assessed and met. Staff knew about each person’s care needs, choices and preferred routines. People said that their care needs were met in a flexible way with staff being happy to adjust the assistance they provided according to the person’s changing needs and wishes. However, we found that some aspects of people’s care needs were not being reliably met. In particular, there were shortfalls in the arrangements used to ensure that people had enough to eat and drink. In addition, there were oversights in the way people were assisted to keep their skin healthy by reducing the risk of pressure ulcers. Some relatives said that they had not been promptly informed when person’s care needs had changed.

Is the service safe?

Staff understood their roles and responsibilities to ensure that people were protected from the risk of abuse. There were reliable systems for managing people’s medication so that medicines were used safely and consistently. People were protected against the use of unlawful or excessive control or restraint because the provider had made suitable arrangements. These measures helped to keep people safe from abuse and to promote their welfare.

Is the service effective?

People were helped to stay safe by avoiding most risks to their health and safety. There were safe working practices to help people with reduced mobility so that there was a reduced likelihood of people experiencing falls and accidents. However, other risks had not been effectively managed. These included the risk of people being burnt because some radiators were not guarded. In addition, repairs had not been promptly completed to ensure the safe and reliable operation of the passenger lift. Some of the people who used the service considered that more staff needed to be provided. On a limited number of occasions the provider had not always arranged for all care worker shifts to be filled. Although this had not directly affected the quality of the service people had received, the situation increased the risk that people would not promptly receive all of the care they needed in the future.

Is the service well led?

People had been consulted about their experience of using the service. There was a clear line of management. This meant that important decisions about organising someone’s care were made by senior staff while carers could use their own judgement to provide a flexible service. The quality assurance system was not robust in that some checks had been overlooked and others had not been completed correctly. These shortfalls had allowed problems in the delivery of care to continue and potential environmental risks to remain unresolved.

On our previous inspection of this service we identified concerns that records were not being maintained in a manner that helped to ensure that people who used the service received effective and safe care and support.

We asked the provider to send us an action plan to inform us of how they would address these concerns.

On this visit we looked at information the provider had sent us, spoke to the registered manager and looked at records.

We saw that the provider had implemented a new system of care plans to better support staff in completing records that related to people's care and welfare.

The provider had taken the appropriate action to address our concerns to help ensure people received appropriate care and support.

We used a number of different methods to help us reach a judgement on the quality of service provision. These included talking with four people who used the service and three relatives who were visiting the home. We also spoke with the registered manager, the provider’s training and audit manager, a nurse and four members of the staff team.

We looked at records. These included care plans and information about how the service was managed. We conducted a tour of the building and observed the interactions between the care staff and people living at the home.

We saw that there were sufficient numbers of suitably qualified and experienced staff to enable people to be supported in a safe and appropriate manner. We spoke with a visitor whose relative was confined to bed through illness who told us, “(My relative) has a special bed to prevent pressure sores. The staff come every two hours to re-position them and medication is dealt with straight away.”

The provider had systems in place to regular monitor and assess the quality of the services provided.

Some of the records that related to people’s care were incomplete and failed to show that people’s needs had been assessed and / or their care plans updated to inform care staff of how to support people in a safe and appropriate manner.

Due to the complex needs of some of the people using the service we used a number of different methods to help us understand their experiences when we undertook our visit.

We spoke to five people living at St Andrews, two relatives of people living there, together with the Registered Manager, four members of staff and a Director of the company that owns St Andrews.

We also looked at records. These included care plans, records of meetings and information about how the service operates. We also looked at information from surveys undertaken by the provider to assess the quality of service.

The people we spoke with said they were happy with the care and support they received and felt it was delivered in a safe way. They told us that staff offered them choice and respected their opinions while encouraging them to be as independent as possible.

One person living at the home told us, “I think the staff are lovely. They try and keep me jolly, you know.”

People also said they felt confident taking any suggestions or concerns to the manager or any of the staff team. They were satisfied with support they received and the service provided.

The people we spoke with raised no concerns other than one told us that sometimes they had to wait a long time for the call system to be responded to by staff. However another person we spoke to said, “If I ring the bell they always come. They do anything you ask.”

The people we spoke with said they were very happy living at the home. One person commented, “It’s wonderful here, they are really looking after me well”. Although people could not always remember being involved in planning their care they told us how staff understood what help they needed and their individual preferences.

People told us about the different activities available at the home and said they enjoyed taking part. However they confirmed that if they preferred not to participate their wishes were respected. They also told us they enjoyed their meals and said they were offered alternatives if they did not want the choices offered.

People told us they could speak to staff about anything they were not happy with. One relative said they chose the home because it was homely and friendly and it had been a good choice.

People said that were happy with their rooms and the general facilities offered. When we asked if there was anything they would like improving most people said “nothing”. However one told us they found the call bells too loud at night.

Most people said they felt there were enough staff on duty to meet their needs and they did not have to wait too long to be helped. However, one person said they sometimes had to wait for their bell to be answered adding, “on the whole the staff are very good, but they always seem in a hurry”.