This inspection took place on 17 December 2018 and was unannounced. We last inspected this service on 30 March 2017 and rated the service ‘Requires Improvement’ overall and in each of the five key questions. At our earlier inspection in July 2016, we had identified that the provider was in breach of seven regulations and people received poor and unsafe care. Following this inspection, we placed the provider into special measures. Our last inspection in March 2017 found the provider had met those previous breaches and was no longer in special measures. The provider had made some improvements to move from an ‘Inadequate’ overall rating, to a ‘Requires Improvement’ overall rating.

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,

This inspection took place on 30 and 31 March 2017 and was unannounced. St Clements Nursing Home is a care home with nursing for up to 37 older people, some of whom have dementia. At the time of our inspection 28 people were using the service. The property is purpose built and accommodation is on two floors with a passenger lift to facilitate access.

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

This inspection took place on 19 July 2016 and was unannounced . At the last inspection on 28 May and 3 June 2015, we asked the provider to take action to make improvements in how they managed risks to people, how people were supported to be independent and systems to ensure the quality of care people received was monitored and improved upon. We found that the provider had failed to take effective action to address most of our concerns.

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

During our inspection we looked at information to help us gather evidence about the quality of care and support people that lived at the home received. The registered manager told us that 32 people lived at the home at the time of our inspection.

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.

There were 29 people living at the home at the time of our inspection, we spoke with 10 people, a relative four staff and the manager. We also spent time observing how people were being cared for.

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.

When we inspected the home on 20 July 2012 people that lived at the home told us that they were happy living there. However we found that there were shortfalls in the systems for obtaining people’s consent to care and treatment, medicine management and training and supervision for staff.

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.

There were 30 people living at the home at the time of our inspection and this included one person who was in hospital. We spoke with six people who lived at the home and one visitor. We spoke with the provider, manager and five staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. This was because some people who lived at the home had dementia care needs and were not able to tell us about their experience.

We found that systems were not in place to ensure that people who use the service and their representatives were able to give their overall consent to their care and treatment.

People told us that they were happy living at the home. One person said “I enjoy living here, they look after us good and proper and we have a joke with all the staff.” We saw that people were treated well by the staff and their care needs were being met.

We saw that people were supported to eat and drink to ensure their food and fluid intake was maintained. People told us that they were given a choice of foods. One person said “We get a choice of meals and we get enough to eat at each meal.”

We saw that the home was clean and fresh and people told us that their rooms were cleaned daily.

We found that the systems for managing medicines were not sufficiently robust and improvements were needed.

People told us they were treated well by the staff that supported them. We found that staff did not receive the training and support they needed to do their job.

People told us they had no concerns about the home. They told us they would speak with the manager if they had any concerns. We found that the systems for monitoring the service to ensure that people received a quality service had improved.

We found that the provider had improved the way records were maintained in the home.

There were 32 people living at the home at the time of our visit and this included one

person who was in hospital.

We were not able to gain the views of some of the people who lived at the home due to their level of dementia and communication needs. We observed the care and support being provided at the home and we talked with people about their experiences of the care. People who were able to speak with us were complimentary about their home. Comments from people included “They look after me pretty well”, “The home’s very good” and ‘’I usually get good care, it has its ups and down but it is usually okay.’’

People told us they were satisfied with the meals on offer. Comments from people included ‘’The food is lovely, I get a choice’’ and “It’s alright, I’m very satisfied.”

We spoke with people who lived at the home about staffing. The majority of people were happy and told us that staff come and help them when they need it. One person told us ''Staff come when I use the buzzer but sometimes it can take longer if they are helping someone else.’’ Another person told us ‘’Staff come when I use the buzzer, I do not have to wait long.’’

People who lived at the home told us they would feel confident in raising any concerns they had. One person told us ‘’I have not needed to make any complaints but would feel okay in telling the staff’’, another person told us ‘’Staff listen’’.

At this visit we spoke to people who live at the home as well as a relative who was there during the inspection. People we spoke to reported being happy. One person told us ‘’ I get a wash every day and can have a shower if I want one, I have never been refused anything here’’. We were told by a relative that ‘’ I did not like the previous home but since X has moved to St Clements I have seen a big improvement in him and he’s started eating, not a lot but it’s a start”.

We spoke with people who live at the home about staffing. The majority of people were happy and told us that staff come and help them when they need it. We spoke with a relative during our visit. They told us “Staff are very kind and friendly and they treat him as one of their own”.

Some people at the home were not able to tell us their views due to their level of

dementia and communication needs. To enable us to understand what their

experiences of living in the home were we undertook an observation of the care

provided. During our observations, most people got the care and support they needed. We found that most people had good levels of interaction with staff but some had very little interaction.

This was an unannounced inspection, which took place on 28 May and 3 June 2015.

St Clements is a privately owned care home situated in a residential area of Birmingham. Nursing care is provided for up to 37 older people. At the time of this inspection there were 29 people living there.

There was a registered manager in post at the time of 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.

Whilst people felt they were safe, we found that procedures were not always adhered to keep people safe from harm. Senior staff were not always aware of what action to take to ensure people were safe from harm. We found instances where the systems and processes were not operated effectively, to investigate allegations of abuse and as a result, the outcomes for people were unclear and therefore people were not always safe.

People did not always receive their medicines in a safe way and medicine procedures were not always followed to ensure people’s safety.

Training and supervision was provided for staff, but not all staff demonstrated they were competent and confident in their role. Some nursing staff were not aware of specific medical conditions of people, so may not be able to take appropriate actions, should people require medical attention. This put people at risk of receiving ineffective care and treatment.

People’s health care needs were met, but their rights were not fully protected. This included where people expressed a wish to leave the home. People enjoyed their food, but choice of food and drinks were sometimes limited and sufficient consideration was not given to people’s specific dietary needs.

People felt staff were caring towards them and their privacy and dignity was respected. We found people’s independence was not always promoted and they did not always get the care and support they needed to remain as independent as possible.

People could raise concerns with the manager, but the system for investigating recording and responding to complaints was not robust. Where complaints were investigated we could not tell the outcome for people.

Whilst people could speak with the manager if they needed to. We identified poor leadership within the service. We found that the provider did not have effective processes and structures in place to ensure people received a quality service and we found several breaches in the regulations. Procedures were not followed effectively and monitoring arrangements failed to identify the failings that our inspection identified

The action we told the provider to take can be seen at the back of the full version of this report.