About the service: St Georges Care Home is a residential care home that is registered to provide accommodation and personal care to a maximum of 35 people. At the time of our inspection, 25 people were living there.

People’s experience of using this service:

¿ People told us and we observed that staff were kind and caring in their interactions with them.

¿ The systems for checking the quality and safety of the service had again failed to identify where improvement was required. Audits were not sufficiently robust to identify concerns we found during this inspection. This put people at risk of potential harm.

¿ Further improvement was needed to ensure identified risks contained clear guidance on how these should be managed. Some risks, such as choking, did not have an associated plan of care to guide staff on how to reduce the risk, and action to take if a person was to choke. Where people had health conditions such as epilepsy or diabetes, there were not always risk assessments in place so staff knew how to recognise signs that they were becoming unwell and how to support them if their health condition deteriorated.

¿ Care plans were now more person-centred and included information on people’s life history and what their preferences were in relation to how their care was delivered. However, we found that care plans were not always sufficiently detailed where people had health conditions, and sometimes there was conflicting information contained within them.

¿ Food and fluid charts were in place for people at risk of malnutrition or dehydration so staff could monitor this. However, we found some conflicting information in care plans relating to people’s dietary needs.

¿ The Mental Capacity Act 2005 Deprivation of Liberty Safeguards were not fully understood by the registered manager. Applications to deprive people of their liberty had not been made in line with this Act to ensure care was lawful.

¿ People received their medicines by staff who had received relevant training. However, medicine administration records were not always completed in line with best practice, and we found two medicines in use had expired. Staff were not periodically assessed for competence in managing people’s medicines.

¿ Staff received training relevant to the people they were caring for. However, other areas of required training, such as diabetes, management of challenging behaviours and end of life care had not been planned.

¿ Staff understood the need to keep people safe from abuse and what was required to do this. Staff had received training in this area, and were clear they would report concerns to a manager or appropriate outside agency without delay. However, referrals had not always been raised by the registered manager.

¿ The overall rating for this service remains ‘Requires Improvement’. The rating for well-led is inadequate. This is the second consecutive inadequate rating for well-led, which means the service will now enter 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 act 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

St Georges Care Home is a residential care home registered to provide support to 35 people, some of whom were living with dementia. At the time of inspection there were 30 people using the service.

At the last inspection on 19 January 2017 the service was rated Requires Improvement overall. The service was breaching Regulation 9: Person Centred Care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service provided us with an action plan stating how they intended to improve in this area. At this inspection we found that the service had failed to make sufficient improvements to comply with this regulation. The service remains ‘Requires Improvement’ overall.

There was a registered manager at the service. 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.

Risks to people were not always identified and clear plans to mitigate risks were not in place for all the people whose records we reviewed. The registered manager and care staff did not always recognise risks in the environment, such as items which could cause potential harm. Care planning did not always make it clear how care should be delivered to ensure people’s safety.

The service was meeting the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS.) People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Care planning around nutrition and hydration was not consistently clear about the support people required. The service did not follow NICE guidance around the assessment of nutrition and the actions required when people were assessed as at risk of malnutrition. NICE guidance is publically available and provides the reader with up to date information about best practice in providing care to people.

People and/or their representatives were not consistently involved in the planning of care. People told us they didn’t think they had been involved in creating their care plans and the records we reviewed did not reflect people’s views and preferences.

People’s records were not sufficiently personalised to include information about their likes, dislikes, hobbies and interests. Where people were living with dementia, there were not sufficient life histories in place. Care plans did not set out peoples preferences around how they would like their care delivered. This meant that staff did not have the information needed to deliver personalised care.

Sufficient end of life care plans were not in place. The service had not referred to NICE guidance and the Gold Standards Framework to create care plans that set out people’s wishes and needs in sufficient detail.

Whilst some work was being carried out to replace carpeting in some areas, the carpets in other areas remained heavily stained and required replacement.

Whilst the service had implemented some new audit systems and processes since our previous inspection, progress to comply with regulations remained slow. The service has been rated ‘Requires Improvement’ since 30 April 2015. At this inspection the service remains ‘Requires Improvement’ and in breach of regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not carry out robust, thorough and questioning audits of the service capable of identifying areas for improvement. The provider had not ensured that appropriate support was given to the registered manager to make the required improvements to the service. This meant that people continued to receive care which fell below the expected standard.

People and thei

St Georges Care Home provides accommodation, care and support for up to 35 older people, some living with dementia. There were 28 people living in the service when we carried out an unannounced inspection on 19 January 2017.

A registered manager was 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.

At our comprehensive inspection of 13 and 21 July 2016, we found there were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were needed regarding staffing, safe care and treatment, person centred care and respect and dignity. A warning notice was served to the provider and registered manager for failing to comply with good governance.

We met with the provider’s nominated individual and the registered manager 13 October 2016 to discuss their action plan in response to our inspection findings. We were given assurances that the shortfalls would be addressed.

During this inspection we found that improvements had been made in the service and were ongoing. Although the warning notice had been met, further improvements to staffing arrangements and people’s meal time experience were required. The registered manager had made improvements in how the service monitored and checked the quality of care provided but this was a work in progress. These measures need to be sustained and embedded into practice.

People and relatives were complimentary about the care and support provided. Staff respected people’s privacy and dignity and interacted with people in a kind and compassionate manner. They were knowledgeable about people’s choices, views and preferences and acted on what they said.

There was a positive culture within the service; staff was aware of the provider’s values and understood their roles and responsibilities. The atmosphere in the service was friendly and welcoming.

Staff were trained and supported to meet the needs of the people who used the service. They knew how to minimise risks and provide people with safe care. Procedures and processes guided staff on how to ensure the safety of the people who used the service. These included checks on the environment and risk assessments which identified how risks to people were minimised.

Appropriate arrangements were in place to ensure people’s medicines were obtained, stored and administered safely. People were encouraged to attend appointments with other health care professionals to maintain their health and well-being.

People and or their representatives, where appropriate, were involved in making decisions about their care and support arrangements. As a result people received care and support which was planned and delivered to meet their specific needs. Staff listened to people and acted on what they said.

The service was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS). Staff understood the need to obtain consent when providing care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Improvements to people’s care records had been made and were ongoing to ensure they were accurate and reflected individual needs and preferences.

People were provided with the opportunity to participate in activities and to pursue individual interests.

Processes were in place that encouraged feedback from people who used the service, relatives, and visiting professionals. People knew how to make a complaint if they were unhappy with the service.

This inspection took place on 13 and 21 July 2016, and was unannounced.

St Georges Care Home provides accommodation, care and support for up to 35 older people, some living with dementia. At the time of our inspection there were 29 people using the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated Regulations about how the service is run.

At our last inspection 30 April 2015, we found that the registered manager had not sent us information that we expect them to send us routinely in the form of statutory notifications. This is information about important events they are required to send us by law. During this inspection we found that they had addressed this issue.

At the last inspection we found a breach of Regulation 17 HSCA (RA) Good governance. Shortfalls identified the provider was failing to seek and act on feedback from people for the purpose of continually evaluating and improving the service. In addition systems were not in place to monitor the quality of the service and keep records of the outcome.

During this inspection we found there were still problems with the systems in place to assess and monitor the safety and quality of service provision. Leading to a lack of governance and oversight in line with current regulations. Existing quality assurance systems were failing to protect people from the risks of receiving inappropriate or unsafe care and treatment. Appropriate action to independently identify, assess and manage risks relating to the health, welfare and safety of people and others who may be at risk had not been established.

We also found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to staffing, person- centred care, respect and dignity, safe care treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

The provider was failing to ensure that the service was operating effectively to ensure that people were receiving safe and effective care. There were gaps in how the service assessed and monitored the quality of its provision. While there were some quality assurance mechanisms in place, these had proved ineffective at identifying areas for improvement, and not all aspects of the service were being effectively monitored. The provider did not have robust oversight of the service's operations and this was impacting on the quality of the care delivered.

People were not consistently supported by sufficient numbers of staff who were effectively deployed to meet people’s needs. There were occasions, for example at meal times where staffing levels were not appropriately deployed to ensure people had a good mealtime experience. At times care was task focussed and hurried with staff unable to respond to people promptly.

Risk assessments did not consistently provide staff with guidance on how risks to people were minimised. Improvements were needed to ensure people consistently received care and support that was personalised to them and met their individual needs and wishes. Staff did not always respect people’s privacy and dignity and interact with them in a caring, compassionate and professional manner.

People’s experience of how they spend their days was inconsistent. Whilst there were some areas of good practice with regards to group activities and social stimulation there were also several instances where people were left for periods of time with little or no interaction. Improvements were needed to ensure people especially those living with dementia spent their time in meaningful and fulfilled ways.

There were areas in the service where equipment was not always stored

We inspected this service on 30 April 2015 and the inspection was unannounced. St Georges Care Home provides care and support for up to 35 older people, some living with dementia.

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 service is run.

The registered manager has managed this home for many years and has been there longer than any of the staff working there or the people living there. This means that they have an extremely good understanding of the people’s needs having carried out their initial assessment and worked with them since they moved into the home. People’s relatives told us that they have confidence in the registered manager, who always makes themselves available if they want to speak with them. The staff have told us that they also get on well with the registered manager and always feel able to approach them if they need guidance or to discuss concerns.

It is possibly because of their open and relaxed relationship that the registered manager has developed a style of management that does not rely on formality, which has led to them failing to meet our requirements in some areas. People living in the home are not consulted on the quality of the service they received as there are no systems in place to capture that information. Surveys were not sent out to people or their relatives and neither were house meetings held, which would have given people and their relatives an opportunity to discuss concerns and suggest improvements.

Staff have not been offered one to one supervision sessions so that they could discuss areas of concern, discuss their personal development, voice suggestions for improvement to the service or receive direction from their manager in a safe and private environment. Nor did the registered manager arrange staff meetings.

People’s capacity to make decisions for themselves have not been assessed which could mean that people were denied the right to make even the simplest decision about the way they want to live and what they want to do.

The provider monitored the service and produced reports of their visits, the registered manager audited the care practice and records, but did not have any systems in place to record that these audits were carried out.

The registered manager has also failed to send us information that we expect them to send us routinely in the form of statutory notifications, this is information about important events which the provider is required to send us by law. It is important that we receive information about people who live in the service and events that may affect them so that we can monitor their service between inspections.

The registered manager has acknowledged that these systems need to be in place and has assured us that they will be taking action to put them in place.

People are safe because staff are aware of their responsibilities in managing risk and identifying abuse. People received safe care that met their assessed needs. There are enough staff who had been recruited safely and who had the skills and knowledge to provide care and support in ways that people preferred.

There was an open culture and the registered manager encouraged and supported person centred care. People’s health needs were well managed by staff who consulted with relevant health care professionals. Staff supported people to have sufficient food and drink that met their individual needs.

People were treated with kindness and respect by staff who knew them well. People were encouraged to follow their interests and hobbies and were supported to maintain relationships with friends and family so that they were not socially isolated.

We spoke with three people who used the service and one relative of a person who used the service. We also spoke with the manager and two staff members. We looked at five people's care records. Other records viewed included staff training and health and safety checks. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a staff member looked at our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

We saw records which showed that the staff working at the home had access to the service's and the local authorities safeguarding vulnerable adults policies and procedures. We also confirmed that all staff received formal training in safeguarding vulnerable adults on a regular basis. The manager told us that they had not recently needed to make a Deprivation of Liberty Safeguards (DoLS) referral to the local authority. However, they were aware of when this may be needed. We also reviewed records of staff training which showed that training in this area, and the related requirements of the Mental Capacity Act, was provided to staff.

Is the service effective?

People told us that they felt that they were provided with a service that met their needs. One person said, "I am very happy living here."

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. People told us that the staff treated them with kindness.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with their wishes.

Is the service responsive?

People who used the service were provided with the opportunity to participate in activities which interested them. People's choices were taken into account and listened to.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to ensure that people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and district nurse.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The manager had a quality assurance system and records reviewed by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We did not speak with people who used the service during our inspection. The purpose of our inspection was to check that improvements had been made with the provision of staff supervision. We found that improvements had been made.

We spoke with seven of the 30 people who used the service. They told us that they were happy with the service they were provided with. One person said, “It is wonderful, they are very good.” Another person said, “I get everything I need, apart from a new body.” Another said, “It is good.”

People told us that the staff treated them with respect and kindness. This was confirmed in our observations during our inspection. We saw that staff interacted with people in a caring, respectful and professional manner. We found that before people received any care or treatment they were asked for their consent and the staff acted in accordance with their wishes.

We spoke with a person's relative who told us, "I know that (relative) is happy with the food and the people here."

We looked at the care records of five people who used the service and found that people experienced care, treatment and support that met their needs and protected their rights. People were protected from the risks of inadequate nutrition and dehydration.

Staff personnel records that were seen showed that staff were trained to meet the needs of the people who used the service. However, they were not provided with appropriate supervision to ensure they received feedback regarding their work practice.

We found that people were cared for in a clean, hygienic environment and were protected from unsafe or unsuitable equipment.

There was an effective complaints system available.

During our inspection we spoke with five people who used the service, two people's relatives and two staff members. People who used the service told us that they were happy with the service provided. We asked one person if they were satisfied with the care and support they received and they answered, "Oh yes massively." Two people's relatives told us that they were happy with the service that their relatives received. One said, "Always good care, 10 out of 10."

People told us that the staff treated them with respect, listened to their choices and acted on what they said. One person said, "All the staff are lovely." Two people told us about what they had for breakfast and how they always chose what they wanted to eat. Two people's relatives told us that they were consulted about the care that their relatives were provided with and kept updated with issues about their wellbeing. They told us that the staff were always respectful.

We saw that staff interacted with people in a caring and respectful manner. People were offered choices such as what they wanted to eat and drink. Staff were attentive to the needs of people who used the service and responded to verbal and non verbal requests for assistance promptly.

We spoke with seven of the twenty eight people who were using the service at the time of our visit.

People told us that they felt that staff treated them with respect and that their privacy was respected. We asked one person if they felt that the staff treated them well and they said “Oh yes the staff here are lovely.” We asked if the staff were respectful, one person said “Oh my goodness yes and if they weren't they would soon know about it.” They laughed when they told us this and said that they had a good relationship with the staff who supported them.

Five people were asked if staff listened and acted on what they said. One person said that they felt in “Control" when they were supported with their personal care needs. Another person said that the staff ask them what they needed and “I'm not fussy, I'm happy with what they do.”

People told us they felt that their needs were met and their comments included “I am quite happy," and “I am happy with all care they provide."