This inspection was carried out on 24 May 2017. St Georges Care Home provides nursing and residential care for up to 63 people, the majority of whom are living with dementia. At the time of our inspection there were 51 people living at the service.

There was a registered manager in post and present on the day of the inspection. 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.

People were protected from the risks of unsafe care. Risks to people were identified and acted upon including risks around behaviours, nutrition, bed rails and environmental risks. Personal evacuation plans were in place for every person and staff had received fire safety training.

People told us that they felt safe. Relatives felt their family members were safe. We found staff understood how to protect people from the risks of abuse. Recruitment practices were safe and relevant checks had been completed before staff started work. There were now sufficient numbers of care staff deployed at the service to meet people's needs with the use of agency staff to meet the required numbers and further recruitment was taking place.

Medicines were managed and administered safely and people received their medicines when they needed. Staff competencies with medicines were assessed.

Staff were suitably qualified, skilled and experienced to meet people's needs including dementia and challenging behaviours. Staff received appropriate support that promoted their professional development and had regular supervisions with their line manager.

The environment was set up to meet the needs of people living with dementia. Staff understood how to support people to make decisions. Where people had restrictions placed on them there was evidence that these were done in their best interests. Staff had a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) and their responsibilities in respect of this.

People had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. People were given choices of meals and people told us that they liked the food on offer.

People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment.

Staff treated people with dignity and respect and choices were offered to allow people to make decisions about their care. People's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. We saw that staff treated people and their families with care and compassion.

People were able to access meaningful activities that were important and relevant to them. People's needs were assessed when they moved in to the service and on a continuous basis to reflect any changes in their needs. Care plans showed that people and relatives (where appropriate) were involved in the planning of their care.

The provider had systems in place to regularly assess and monitor the quality of the care provided. Complaints were investigated with the necessary action taken. The provider actively sought, encouraged and supported people's involvement that was used to improve the quality of care. Staff were encouraged to contribute to the improvement of the service staff felt listened to and valued. People’s records were up to date or accurate.

People told us the staff and management were friendly and approachable and were always visible in the service.

This unannounced inspection was carried out on 27 April 2016. This inspection was to follow up on actions we had asked the provider to take to improve the service people received. St Georges Nursing Home provides nursing and residential care for people who are living with dementia. The service is registered to accommodate up to 63 people. On the day of our inspection there were 43 people living at the service. The accommodation is a purpose built single storey building.

There was no registered manager in place on the day of the 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 Regulations 2014 and associated Regulations about how the service is run. We were assisted by the new manager that had recently transferred from another BUPA service. They had submitted their application to become the registered manager.

At the last inspection on 14 October 2015 this provider was placed into special measures by CQC. This inspection found that there was sufficient improvement to take the provider out of special measures.

During our last inspection of this service on 14 October 2015 we found breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to take action in relation to staffing levels at the service, the lack of Mental Capacity Act assessments, safe care and treatment was not always provided, people were not always treated with dignity and respect, the premises was not always well maintained, care plans were lacking in detail around the specific needs of people and there was a lack of good governance at the service. The provider sent us action plans weekly and provided timescales by which the regulations would be met. The provider also sent us the updates in relation to progress they had made.

At this inspection we found that improvements had been made and the provider had met the requirements regarding the regulations.

Staff were deployed around the service effectively to ensure that people were kept safe. People and relatives said that there were enough staff to support people.

Risks to people were identified and managed well. Care plans included detail around the risks to people and there was guidance for staff to follow to reduce risks. Robust recruitment practices took place to ensure that only suitable staff were employed. The premises and equipment was well maintained.

Personal evacuation plans were in place for every person who lived at the service. In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe.

Systems and processes were in place to protect people from the risk of abuse. All staff understood how to protect people from abuse.

Medicines were stored securely and administered in a safe way. Medicines Administration Records (MARs) for people were signed for appropriately and medicines were disposed of safely by staff.

People’s rights were protected under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had been completed around people’s capacity however the manager told us that more work needed to be undertaken to re-assess people’s capacity. We have made recommendations in relation to this.

DoLS applications had been submitted to the local authority around whether people’s liberties were being restricted.

People received care from staff who had received appropriate training that centred aroun

This unannounced inspection was carried out on 14 October 2015. St Georges Nursing Home provides nursing care for people who are living with dementia and is registered to accommodate up to 63 people. On the day of our inspection 57 people lived at the service. The accommodation is arranged over two units over one floor. One of the units is for people with more complex needs and who may have behaviour that may challenge.

There was a registered manager in place who was present on the day of the 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 were also assisted by the regional manager.

There were not always enough staff deployed in the service to consistently meet people’s needs. People sometimes waited long periods of time before they received support from staff. There were times where there were less than the required staff needed to care for people safely. There were no assurances that before staff started work appropriate recruitment checks had been undertaken. There were gaps in staff records and appropriate references or checks had not always been obtained.

Risk assessments did not always detail the support people needed. There was a lack of information for staff on some of the identified risks. We found that the environment was not always safe. Some furniture was arranged in way that was difficult for people to manoeuvre. Other risks had been assessed and guidance provided to staff on how to reduce them which included the risk of pressure sores and choking. There had been accidents and incidents recorded but there was a lack of analysis of what the registered manager had done to reduce the risk of falls and incidents in the service.

People’s rights were not always met under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of people by ensuring if there are any restrictions to their freedom and liberty, these have been authorised by the local authority as being required to protect them from harm. Assessments had not always been completed specific to the decision that needed to be made around people’s capacity. DoLS applications had been submitted to the local authority. Other staff did have an understanding of MCAs and DoLS and were able to explain to us the reasons why assessments were undertaken.

People were not always receiving care from staff who had received appropriate training. There was a risk that people were receiving care from staff as they were not always kept up to date with the mandatory training including dementia and health and safety training. Nursing staff were not up to date with their clinical training.

Staff were not always supported in their work and said that they did not have regular supervision with their manager. They said “I don’t know whether I’m doing well or not.” There were over 60 staff who had not had a supervision with their manager this year. There was no opportunity for staff and their manager to discuss their performance or any ongoing training needs.

The environment did not always meet the needs of the people that were living there, particularly those who were living with dementia. There were very few destination points or signage to help orientate people around the service and assist with their independence.

Staff at the service were not always caring. There were times during the inspection where staff were not as supportive as they could be. People were ignored for periods of time throughout the day and on occasions staff chatted amongst each other and did not interact with people especially during the meal time. We did see times when staff were caring and considerate to people. People were complimentary about the staff. One person said “The carers are very good, they are kind”

People felt safe and staff had good knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse. There were clear policies in place to guide staff should they have any concerns. Medicines were stored appropriately and audits of all medicines took place. Medicines Administrations Records (MARs) charts for people were signed for appropriately and all medicine was administered, stored and disposed of safely by staff who were trained to do so.

People’s preferences were not consistently being met. One relative told us that they were involved in their family members care and were contacted about any changes that had occurred. Staff at the service had the details of an advocacy service where people needed the support. The service was not always responsive to people’s needs. There was information missing in people’s care plans around support they needed. One person had been in hospital after having a significant injury but their care plan which had been updated didn’t reflect their current needs. Communication was not always shared with staff about people which put people at risk. The registered manager confirmed this and said that they were working on ways to improve the communication and sharing of information with staff.

There were not enough meaningful activities on offer specific to the needs of people living at the service. There were long periods of time where people had no meaningful engagement with staff. One person said to us “Sometimes it gets a bit boring but I do enjoy the exercises” whilst we heard another person say “I think I will go to bed, this is boring.”

Although people, relatives and staff felt that the registered manager was likeable, many of them reported that management was ineffective. There was not always consistent and obvious leadership in the service and staff said they didn’t always feel supported or valued. Not all staff received annual appraisals to discuss their performance or training and development needs. However some staff told us that the manager’s door was always open and felt that they could go to see them whenever they wanted. One told us “He (the manager) is always very visible and checks everyone is ok, his door is always open.”

There were not effective systems in place to assess and monitor the quality of the service. Audits and surveys had been undertaken with people, relatives and staff but had not always been used to improve the quality of care for people. Records were not always completed accurately and were not always complete. Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had not informed the CQC of significant events in a timely way.

There were times where staff responded appropriately to people’s care. One relative told us “I feel the home is outstanding and the nurses are excellent.” They told us that the staff had responded quickly to their family members’ ill health and felt that the family member would not be alive today without their intervention.

In the event of an emergency, such as the building being flooded or a fire, there was a service contingency plan which detailed what staff needed to do to protect people and make them safe. Where people needed to have their food and fluid recorded this was being done appropriately by staff. Intake and output of food and fluid was recorded on forms that were kept in people’s rooms.

Nutritional assessments were carried out when people moved into the home which identified if people had specialist dietary needs.

People had access to a range of health care professionals, such as the GP, dietician, Parkinson’s nurse and chiropodist. One health care professional told us that staff at the service regularly had contact with the local mental health team.

There was a complaints procedure in place for people to access. The registered manager told us that since taking up post they had not received a single complaint.

The overall rating for this report is ‘Inadequate’. This means that it has been placed into ‘Special measures by CQC. The purpose of special measures is to;

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement power in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such as there remains a rating of inadequate for any key questions overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the providers registration.

During the inspection we found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

During our inspection we set out to answer 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, speaking with people who used the service, the staff supporting them, and from looking at records.

For further evidence supporting our summary please read the full report.

Is the service safe?

The service was clean, hygienic and safe from hazards, providing safe access to all areas of the home.

We saw that systems were in place to record, report and monitor people`s care and treatment needs.

We saw that staffing arrangements ensured that people`s needs were responded to quickly.

Is the service effective?

people`s health needs were assessed with them, and included their relatives as part of the process. Arrangements were in place for people to be supported by other health care professionals, and people`s opinions and views were sought as part of the review process.

Is the service caring?

We saw that people` were supported by kind and caring staff who spoke to them in a polite and respectful manner. People told us " The staff are very friendly , they keep the home nice and tidy, I think its a good one"

The staff were able to tell us about the people that they supported. they new people`s individual histories and support needs without having to refer to the care records. staff were seen to take time to listen to what people said.

People`s preferences, interests and diverse needs had been acknowledged and recorded in people`s care records. There was care support provided to meet those needs and interests. Family links were maintained and family and friends encouraged to visit.

Is the service responsive?

We saw that people were involved in a number of activities. We saw people engaged with staff using reminiscence pictures and memorabilia. We saw people seated talking to friends and relatives in the lounges. We saw that staff were available to respond quickly to people`s needs. We saw that the home held residents and family meeting, that gave people the opportunity to express their views .

Is the service well led?

The manager had a good understanding of the needs of people that used the service, as well as managing the requirements of the home. Staff told us that they were happy with the support from the manager. We saw that people`s care records were updated regularly to monitor the service that people received. This helped to ensure that people received a good quality service at all times.

We inspected St George’s Nursing Home to check that they had made improvements required to meet the essential standards of care. We spoke with two people who used the service and three relatives who were visiting. We also spoke with six members of staff, including the registered manager and area manager. We received five responses to a questionnaire we handed out to staff. Overall, we found that improvements had been made.

We observed how staff interacted with people throughout the day and saw that they did so with kindness and respect. Staff were attentive and respected people’s dignity. We spoke with people being supported by the service who told us “The nurses are always very considerate and very good to me.” We heard that staff had been informed about new Deprivation of Liberty safeguards (DoLS) guidance. The provider told us they had not yet made any applications to deprive a person of their liberty under the new guidance but this was under review.

People’s care plans had been informed by risk assessments such as when a person was at risk of falls. Care plans and risk assessments were updated regularly or when people’s support needs changed. We saw that when people’s needs changed, the service responded in a timely way and communicated this to staff and other agencies. One person we spoke with told us their health care needs were assessed with them, and they were involved in writing their care plan.

We visited St George’s nursing home to check for improvements in the areas of care and welfare, safeguarding and record keeping.

During our inspection we spoke with three people who lived at the home, three relatives and one other visitor. We spoke with three staff members and received four responses to staff questionnaires we handed out. We also spoke with the manager and the area manager.

Overall we found that there had been improvements within the home. We shared our feedback with the manager and area manager at the end of our inspection who agreed that they still had work to do.

People who used the service told us that they were happy with the care they received. We heard that staff were “Friendly” and “Helpful”. One person told us that they thought the staff “Do all they can.” However, we found that some people had not always received appropriate care and support.

We saw that staff were knowledgeable about safeguarding procedures. When asked, staff were able to explain about abuse and how they should report it.

This was a follow up inspection to check that the provider had made improvements in the areas of infection control and record keeping, which we found to be non-compliant at our previous inspections in July and August 2013. We had also received letters of concern about the care and welfare of people at the home, and feedback from Surrey County Council safeguarding team.

During the course of this inspection we identified other areas of concern and included these in our inspection. We spoke with three people who used the service, four staff and two visitors on the day of our visit. Following the inspection we spoke to another five members of staff by telephone. We also spoke to the new manager and recently appointed interim area manager to discuss our concerns. They told us that they were aware that there were improvements required within the home and had put an action plan in place to achieve this. We saw that this was already underway. The new manager told us that they would be registering with the Care Quality Commission and would be working as a full time manager at the home from 1 February 2014.

We found that some staff treated people kindly and with respect. However, people were not always treated with dignity and respect. For example, we observed that some people did not receive the support they needed to maintain their dignity. We found that staff did not always respect people’s wishes.

We saw that the provider had procedures in place for assessing people’s mental capacity. However, we had concerns about how these were implemented.

We saw some examples of kind and compassionate care during our observations. One person told us “I am well cared for. I have no reason to think it should be any different.” However, we found that some people did not receive the care and support that they required.

During our inspection we observed that staff did not always support people safely. For example we saw that people who were at risk of falls were left alone for long periods of time. We raised our concerns with the manager at the time.

We found that there were very strong mal odours throughout the home, including in people’s bedrooms and communal areas. There were not effective procedures in place to manage infection control within the home. The manager told us that there were plans in place which would address this issue.

We had concerns about staffing levels on the day of our visit. We observed periods of time where people needed immediate support and there were no staff on hand. We went to find staff to attend to people’s urgent needs on three occasions during the day.

We followed up on record keeping. We looked at eight people’s care records and found that there were inaccurate and incomplete records of people’s care.

Overall, we found that the provider did not have effective monitoring systems in place to check on the quality of delivery of people’s care and the management and running of the home.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences fully. We spoke to the relatives of six people.

Five people who spoke with us commented positively on the staff, telling us they could not find fault with the home. One relative of a resident at the home said that the resident had settled well into the community and the staff were very kind.

One person told us there were some issues when their relative was admitted to the home four years previously but they had all been resolved, telling us that the staff were really good and looked after their relative well.

One person told us “The staff are brilliant I can’t find fault with them.” Another told us “I’ve observed the staff being very patient with the residents even when they have challenging behaviour. You won’t find any problems here with the staff they’re wonderful and kind.”

We observed on the day of inspection that activities were taking place. The home benefits from three activity organisers and two part time people. There were volunteers also and on the day of the inspection we observed a person attend the activity room to play the piano. In the afternoon there was live entertainment in the lounge with a singer. The people that attended were enjoying the activity and joining in the singing.

During our inspection we spoke with six members of staff, including the members of the management team and catering staff. We also gave questionnaires to four other staff to gain their views. People who used the service were unable to tell us their views due to their mental frailty. We carried out observations and spoke to three relatives of people who used the service.

We saw that staff asked people for their consent before providing any care or support. One relative told us that staff always asked “Would you mind if we do this?”

We saw that staff provided appropriate support to people and attended to their needs promptly.

We saw that there was a choice of healthy and nutritious food, and drinks were available throughout the day. A relative told us “The food is excellent”.

During our inspection we noted that there were strong, unpleasant odours in several areas of the home and raised this with a senior manager.

We observed that there were sufficient staff on duty on the day of our visit. We looked at staffing rotas and noted that staffing levels were in line with what we had been told.

We looked at six people’s care records and noted that four people’s records had not been updated for several months. This was not in line with the provider’s policy of monthly reviews.