We inspected this service on 9 August 2018. The inspection was unannounced. The service provides accommodation and personal care for up to 29 older people. Twenty-three people were living at the home at the time of our inspection.

St George’s home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At our previous inspection on 27 March 2017 the overall rating for the home was ‘requires improvement’ and we asked the provider to make the necessary improvements. At this inspection, we found there had been insufficient action to improve and found additional areas needing improvement across all the key questions. We identified four breaches in the regulations and therefore the home continues to be ‘Requires Improvement’ overall. Breaches related to the safe care and treatment people received, safeguarding people from abuse, not submitting statutory notifications related to incidents at the home and failing to ensure there was good governance of the service.

The provider had not taken all reasonable measures to minimise risks to people’s health, safety and wellbeing. Systems and processes had not been effective in identifying and driving improvement at the home. Following the inspection visit we met with the provider and they explained how they would make the required improvements.

The registered manager in post at our previous inspection had left and a new manager, who had previously been the deputy manager, had been appointed. They were not registered with us at the time of this inspection. The provider told us of their plans for an application to be made for this person to be registered with us. 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.

During this inspection we found numerous reportable incidents had occurred at the home that had resulted in safeguarding referrals being made to the local authority. These had not been reported to us as required. There were also increasing numbers of accidents and incidents within the home and these had not been analysed and considered to help minimise the risk of them happening again.

People had limited involvement in the ongoing review and planning of their care. Staff told us and people confirmed, consent was sought from people before delivering care. The relevant applications had been made where it was considered people were being deprived of their liberty. However, some of the information around people’s capacity was conflicting and the reason for the application was not always clear.

We saw staffing arrangements were not always effective because care staff sometimes completed ancillary duties such as laundry and cleaning. This impacted on the amount of time staff could spend with people as well as the amount of time that could be spent keeping all areas of the home clean.

Some staff had not completed training the provider considered essential to manage people’s care safely. Some staff practice was not safe such as techniques used to move and transfer people although we saw further training was planned.

Systems did not consistently demonstrate that people always received care and support in accordance with their needs.

Health and safety checks were completed such as gas, electrical and water to ensure both equipment and the environment was safe for people. However, audit checks of the environment and equipment were not consistently effective as we had identified some potential risks. This included risks related to infection control and the home not being sufficiently secure t

This inspection took place on 27 March 2017 and was unannounced.

St George’s Home provides personal care and accommodation for up to 29 older people. There were 24 people living at the home at the time of our inspection. This included a number of people 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.

During our last inspection on 5 May 2016, the provider was not fully meeting the standards required in relation to the “Safe” “Responsive” and “Well Led” key questions. The registered manager and staff did not have sufficient knowledge of what constituted abuse and referrals were not being made to the Local Authority and notified to us as required. We asked the provider to take action to make the necessary improvements.

During this inspection we found some action had been taken to ensure safeguarding referrals were made to the Local Authority, but there continued to be some that were not reported to us as required. Safeguarding systems and processes remained in need of improvement as they were not sufficiently clear to ensure people were protected from potential abuse. Both the registered manager and staff continued to have gaps in knowledge of what constituted abuse.

Despite safeguarding processes not being clear, people told us they felt safe living at the home and we saw there was enough staff on duty to keep people safe and meet their needs. People received their medicines as prescribed but the procedures for managing prescribed creams were in need of review to ensure these were being managed safely and effectively.

Staff were knowledgeable about the risks associated with people’s care and knew people's needs varied according to their abilities and preferred routines. However, risk assessments and management plans for people were was not always clear enough to provide guidance to staff to minimise risks.

People were able to access healthcare professionals when they needed to ensure their healthcare needs were met.

Recruitment checks were carried out prior to staff starting work at the home to make sure they were suitable for employment. New staff received an induction to the home to prepare them for their role and all staff had access to ongoing training to develop their skills and knowledge.

The manager and staff understood their responsibilities under the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). People who lacked capacity were supported in decision making, and where appropriate, applications had been made to authorise any restrictions on their freedom that were in their best interests.

People received a choice of meals and overall people were positive about the food provided. Drinks were regularly made available to people so they had enough to drink.

Some group social activities were arranged and some people were taken out on a one-to-one basis, however, activities were not consistently provided in accordance with people’s needs, preferences and wishes.

Staff were kind and patient and showed respect to people. People were encouraged to maintain relationships with people important to them and visitors were welcomed at the home.

A complaints procedure was in place and complaints received had been appropriately investigated. People and their families were positive about the care being provided and they told us they knew who to approach if they had a complaint.

People, their visitors and the staff were positive about the management team and the running of the home. There were processes to monitor the quality and safety of the service provided but some of these were in need of review to ensure the quality of care and

This inspection took place on 10 March 2016 and was unannounced.

St George’s Home provides personal care and accommodation for up to 29 older people. There were 25 people living at the home at the time of our inspection. This included a number of people 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.

We could not be sure the registered manager and care workers had sufficient knowledge of what constituted abuse because referrals were not always made to the local authority when safeguarding concerns were identified.

People told us they felt safe living at the home and we saw there was enough staff on duty to keep people safe and meet their needs. Medicines were managed safely so that people received their medicines as prescribed.

Risks associated with people’s care had been assessed to keep people safe however; records did not always reflect current risks and records were not always kept up to date. Care workers we spoke understood of the risks associated with people’s care.

People were referred to external healthcare professionals to ensure their health and well-being was maintained.

New staff received an induction to the home and staff received training in health and social care on an on-going basis to help develop their skills and knowledge further.

Recruitment checks were carried out prior to staff starting work at the home to make sure they were suitable for employment.

The manager and staff understood their responsibilities under the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS) to ensure people were looked after in a way that did not inappropriately restrict their freedom.

People received a nutritious diet, had a choice of food, and were encouraged to have enough to drink.

Some group social activities were arranged, however, people told us they would like more variety and would enjoy more days out.

Staff were kind and patient and showed respect to people. People were encouraged to maintain relationships with people important to them and visitors were welcomed at the home.

A system was in place to manage complaints received about the service. People and their families were positive about the care being provided and they told us they knew how to make a complaint.

People, their visitors and the staff were positive about the management team and the running of the home. There were processes to monitor the quality and safety of the service provided.

We found a breach 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.

This inspection was completed by one inspector. We spoke with three people and three relatives of people who used the service. We also spoke with the registered manager, a senior carer, two care staff and a domestic assistant. During this inspection we also spoke with a district nurse who was visiting a person who used the service. The evidence we collected helped us to answer five key questions; is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and staff told us.

If you want to see the evidence that supports our summary, please read the full report.

Is the service safe?

People we spoke with told us they felt safe. One person we spoke with said: “Oh yes, the staff are ever so kind and helpful.” Another person told us: “I can lock my door if I want but there is no need to.” The three relatives we spoke with all said they had no concerns about their relative staying at St George's.

The provider and staff understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager and staff were able to describe when an application should be considered and who should be involved in the process. We saw records that showed a number of staff had received training in mental capacity. The registered manager told us further MCA and DoLS training was booked in light of the recent ruling in these areas.

The home was clean and tidy with no unpleasant odours. The registered manager had implemented cleaning schedules which made sure people’s rooms and communal areas were regularly cleaned. People and relatives we spoke with told us they had no concerns about the cleanliness of the home or their relatives’ room.

People told us if they needed anything repaired or replaced, this had been done with minimal delay. We saw maintenance records that confirmed repairs had been undertaken promptly.

We found equipment was maintained and regularly serviced. We found the provider carried out regular fire checks and ensured people and staff knew what to do in the event of an emergency.

We looked at staffing levels and found staffing was calculated on people’s individual dependency levels. The registered manager told us they had recently recruited two additional staff. Staff we spoke with told us that staffing levels enabled them to meet people’s needs.

Is the service effective?

People had an individual care plan which explained what their needs were. People and relatives told us they had been involved in the care assessment and their contributions were listened to. Risk assessments were reviewed and identified current risks.

People had access to health care professionals which supported their health care needs.

We found staff had received the necessary training that enabled them to provide suitable and appropriate care for people.

Is the service caring?

People were supported by staff that provided care at people’s preferred pace. Staff were kind and attentive and responded appropriately to people’s requests. Staff promoted individual choice and supported people who wanted to remain as independent as possible. We found individual wishes were taken into account.

Is the service responsive?

People received help and support from other health professionals when required, such as doctors, dentists, occupational therapists and chiropodists. We found people had received oral treatment from a visiting dentist prior to our inspection. We also saw people were supported by a district nurse.

People were supported to participate in activities inside and outside of the home.

The service had systems in place to monitor the care provided to people. This included regular reviews with people and relatives. We found the provider held residents meetings to seek the views of people who used the service. We saw actions were taken when improvements had been identified.

People told us that concerns were listened to and acted on. People and relatives told us the staff and managers were very approachable.

Staff said they had a handover at the start of each shift to update them of any changes in people’s needs since they were last on duty.

Is the service well led?

The service worked alongside other health care professionals and agencies to make sure people received the care they required.

The service had an effective system in place that assured them of the quality of service they provided. The service completed regular checks and sought the views of people who used the service. The service also gained the views of staff and we found the service listened and acted upon these views.

People’s care records and other records were accurate, available and completed.

We visited St George’s Home on Tuesday 18 June 2013. There were 26 people at the home on the day of our visit. We spoke with several people who lived in the home, the manager, all the staff on duty and a visitor to the home. We spent time in the communal areas observing people’s experience and how staff interacted with people.

We found that were possible people had given their consent to the care and treatment to be provided. We saw that staff asked people about their choices. We found that staff had a good knowledge of people's care needs and were aware of people’s preferences.

We asked people what it was like to live at St George’s. People said, “It’s a good place, I’ve only been here a little while but everything has been okay so far” and “It’s a nice place, you get plenty of choices and staff treat you well.”

We looked in detail at the care provided to three people who lived at St George’s. The care and support plans we viewed held good information and were easy to understand.

We looked at the medication procedures in the home. We found there was a safe procedure for handling medicines and people received their medication as prescribed.

We looked at how staff were recruited. We found the recruitment procedure made sure staff were properly checked before working in the home. Staff had the skills and knowledge to support people who lived at St George’s.

All the records we requested to see were available. Documents we viewed were accurate and up to date.

During our visit we spent time observing staff and people living at the home. We saw that people felt relaxed and at ease with staff who were familiar with individuals and their daily routines. Staff referred to people by name and talked to people in a respectful way.

Staff told us that they support people to maintain their independence and to do things for themselves if possible. One resident said “I make all my own decisions, but carers are around if I need help with anything”. We spoke with a visiting family member. We were told that they were happy with the home and that staff knew their relative well.

We looked at a sample of care files and saw that people and their relatives’ complete a ‘personal profile’ document. This provides staff with information about the person’s life including their likes and dislikes. We found that people had been involved in their care planning process and decisions about living in the home.

People told us that they were well looked after and were happy with the care at the home. They said that everyone received plenty to eat and drink, that the food was good with a varied menu. We observed people being supported during lunchtime. People who needed support with eating their food were provided with assistance in a sensitive and dignified way.

Staff knew what to do to keep people safe. We were told they would have no hesitation reporting concerns or poor practice to the manager. Staff said they were confident their concerns would be listened to and acted on.

We looked around the home and found that this was clean and people had the equipment they needed to be comfortable and safe. We found that improvement had been made to the overall upkeep and maintenance of the home. However we have asked the provider to take a proactive approach towards the refurbishment and maintenance of the home, to ensure the home maintains compliance.

People who use the service were asked for their views about their care and treatment. We looked at the results of the surveys undertaken in March 2012. Returned questionnaires demonstrated that residents and their relatives were satisfied with the care provided by the home.

When we visited the home on 22 July 2011 we asked a person whose care we followed if they got the care and support that they needed and they told us that they did. We spent four hours in the open plan public rooms observing the care of another person who was not easily able to talk to us. We saw that they were helped and encouraged by staff to eat and exercise and participate socially but were not pressed when they declined. A family member who was visiting told us they were very pleased with the home. They said the home had looked after one of their relatives before and then they fought to have their other relative admitted. They said that nothing was too much trouble, the staff were very kind and they and their children and grandchildren were always welcome. "It’s a lovely home". They also said that the lounges were quieter with just one TV playing at a time now. A family member of another person said they were very satisfied with the care their relative received at the home and their relative had put on weight since moving in as they had not been eating when they lived at home alone. When we visited the home on 25 July 2011 we spoke to a person who had drawn our attention to the absence of grab rails in one of the toilets at our last visit. They told us that the toilets and bathrooms were easier to use now. We asked them if the home was sufficiently staffed. They said there seemed to be enough staff around lately but there were less residents in the home anyway.

When we visited the service on 15 February 2011 we spoke to a person who uses the service about the level of involvement that they have in the running of the home.

She told us "I'm happy with the way things are run, especially with the food. I was unwell the other day and I didn't want to get up. I just rang my bell and they were there to look after me. What more could you want? They run our lives for us".

Another person told us that she did not feel well that day. She said that staff had been up to her room a number of times to check on her and they would bring her up some lunch later.

There were a number of people with dementia living at the home that could not easily speak with us and give their views. We relied on our observations of their body language, behaviour and the way that staff interacted with them to make our judgements about how comfortable and safe they were.

People living in the home with dementia could not easily find their way around. Bedroom doors had numbers on them but no other means to distinguish one from another.

People spent most of the day in an open plan communal area that was large and noisy. Staff encouraged one person to sit in a chair between noise from a loud television, the motor of the chiller cabinet and back ground noise from the working kitchen. Her care plan said that she needed a stress free environment. She was continually trying to get out of her chair.

People did not have enough staff around them to be treated as individuals. At one point in the day, one end of the lounge area was supervised by just one member of staff watching ten seated people. One person got up from his chair. He was told to sit down again by the care assistant. She put her hand on his shoulder as she told him this.

Another person went to the kitchen door mid morning. He was told by kitchen staff to wait for his tea. He turned away. He got his tea with everyone else fifteen minutes later.

No activities were organised that provided individual attention to people.

People were left sitting in one part of the lounge that had a persistent bad odour.