The inspection took place on 29 and 30 November 2016. The inspection visit was unannounced on 29 November 2016 and we informed the manager we would return on 30 November 2016.

St George's Nursing Home is registered to provide both nursing and residential care with accommodation for up 43 people. People who live at St George's Nursing Home all had needs relating to their health, and some people were also living with dementia. At the time of our inspection there were 11 people living at the home.

A registered manager was not 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. The provider had recruited to the role of home manager and this manager was in the process of registering with the Care Quality Commission [CQC].

At our previous inspection on 20 and 21 April 2016, we found five breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. These breaches were in relation to person centred care, safe care and treatment, premises, staffing and good governance. The home was placed in 'Special Measures.' The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months.

We also took enforcement action by imposing a condition on the provider’s registration to restrict admissions to the home. This was because of the significant concerns about the safe care and treatment of people who lived at the home.

At this inspection we looked to see if the provider had responded to make the required improvements in the standard of care to meet the regulations. Whilst we found areas of improvement had been made to meet some of the regulations the provider continued to be in breach of the legal requirements and regulations associated with the Health and Social Care Act 2008. These were in relation to safe care and treatment and good governance.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

The provider had management procedures in place but these were not consistently effective. Where improvements were required these had not always been assessed for their effectiveness and sustainability. At this inspection we found there was a continued lack of a consistent strong vision and oversight of the service to support people in receiving safe, effective and responsive care which was well led.

We found there were inconsistencies in the provider's systems and staff practices to provide assurances that all risks to people were safely and effectively managed. We found the management oversight of incidents did not provide confidence in how these were consistently followed through. There were aspects of staff practices which did not assist in the prevention of reducing cross infections and accessible items could place people at risk of harm.

The provider had employed a maintenance person who had assisted in the improvements in the repairs within the home. Since our previous inspection work had been carried out on the water supply so the risks to people of scalding and/or their personal care needs neglected had been reduced. The temperature of the hot water supply had been regularly tested by the maintenance person.

People’s medicines were stored securely and made available to people as prescribed. Safety meas

The inspection took place on 20 and 21 April 2016 and was unannounced.

St George’s Nursing Home is a care home and the provider is registered to provide both nursing and residential care with accommodation for up 43 people. People who live at St George’s Nursing Home all had needs relating to their older age, and some people were also living with dementia. At the time of our inspection there were 19 people living at the home.

A registered manager was not 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. The provider had recruited to the role of home manager and this manager was present at the time of our inspection.

At this inspection we found the provider was in breach of four of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were Regulation 12 in relation to safe care and treatment, Regulation 18 in relation to staffing, Regulation 9 in relation to person centred care and Regulation 17 in relation to the governance of the service. These breaches in Regulations are described throughout all sections of this report.

People were not always kept safe from harm as risks to their wellbeing and safety were not identified and managed with timely action taken. The provider’s systems and staff practices did not provide assurances all incidents which placed people at risk of harm had been reported with the appropriate action to keep people safe.

People were put at increased risk of infections because the provider’s systems and staff practices did not ensure people lived in a clean and hygienic home. This included the equipment staff used to assist people and the furniture in the home to make sure people were not at risk from cross infections. Staff practices around carrying used needles around the home when they should be place straight after use in the appropriate container did not promote people’s safety from injuries or infections.

People’s safety and wellbeing was not promoted as there were hazards around the home environment and action had not been taken to reduce these. Staff practices did not make sure people were provided with safe and effective care due to the provider’s inconsistent water supply which meant staff carried hot water around the home increasing the risks of scalds.

People were supported with their medicines. Medicines were ordered, stored, administered and disposed of safely. Staff did not have detailed information about people’s when required medicines

People received healthcare support to maintain their nutritional needs when required. The manager showed they led by example and was ensuring staff consistently assisted people with their meals where this was required as some people had been losing weight.

People were supported to make choices about their everyday care and support. There were some procedures in place to ensure where people were not able to make specific decisions themselves in their best interests. These were not always effectively organised to enable staff to easily access this information and to ensure people’s rights were upheld through staff practices.

Staff had some positive caring conversations with people which enhanced their wellbeing. Other staff practices were based around tasks as opposed to considering each person’s feelings. People’s privacy was promoted by staff who recognised and respected.

Staff did not have the confidence or knowledge to respond to the identified needs of some people who had come to live at the home. The provider had not made sure before agreeing individual people’s needs could be met at the home they had increased staff’s knowledge and tested their competence in providing the individual care

The inspection took place on 29 July 2015 and was unannounced. St George’s Nursing Home is a care home and the provider is registered to provide personal and nursing care for up to 43 people. The provider had reopened the home in November 2014 and at the time of our inspection 16 people lived at the home.

A registered manager was in post and 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.

There were some arrangements in place to assess, monitor and improve the quality of the care but these were not always effective. This is because the checking systems had not identified some areas that required improvement actions to be taken. There were potential hazards which directly placed people’s safety and wellbeing at risk such as an exposed hot water pipe and aspects of a shower room were unclean which included the shower tray.

Staff were aware of any risks to people and were available when people needed assistance, care and support so that risks to people were reduced. However, the aids to meet a person’s needs and reduce risks to their wellbeing were not available as stocks had run out.

People were kept safe from potential abuse and harm by staff who understood how to identify the various types of abuse and knew who to report any concerns to. Staff were trained and supported to meet the needs of people who lived at the home. We heard some examples where people’s health and physical needs had improved due to effective staff practices. Checks had been completed on new staff to make sure they were suitable to work at the home.

People’s medicines were managed safely, and people were supported to manage their own medicines wherever possible. We saw medicines were stored correctly in locked cabinets and there was a clear process for recording and daily checks were in place so that all medicines could be accounted for.

People were asked for their consent for care and were provided with care that protected their freedom and promoted their rights. Staff asked people for their permission before care was provided and gave people choices about their support. In some people’s care records there was some inconsistency in the documentation used to record people’s capacity to make specific decisions. This had not impacted upon decisions being made in people’s best interests. People enjoyed the food they received and were supported to eat and drink enough to keep them healthy. When people needed it they had access to a range of healthcare professionals to make sure their nutritional needs were met and they remained healthy and well.

Staff had caring relationships with people and knew each person’s individual preferences and needs well. People felt staff treated them with kindness and they felt involved in their care. Staff respected people’s privacy and personal space. People who received some of their care in their rooms were checked regularly by staff who had assessed the frequency of these checks. We saw staff asked people’s permission before they entered their rooms to support people with their care needs.

People were treated as individuals as staff knew people’s needs and their individual preferences. People told us staff responded to their care and support needs at times people needed it and were not kept waiting for unreasonable amounts of time.

People knew how to make a complaint and told us they felt able to discuss any concerns with staff or the registered manager. The registered manager was visible in the home so that people were able to approach them with their concerns and views of their care. However, they recognised they needed to provide people who lived at the home with other ways of giving their opinions of the home such as through meetings.

Staff were clear about their roles and spoke about people they supported with respect. The registered manager was building up an established team of staff so that people had continuity of care from staff they knew well. Although one of the key challenges for the registered manager was the recruitment of nurses they had worked to resolve this.

The registered manager was responsive to the issues we found at this inspection. They had made some recent changes which included increasing the hours of housekeeping staff to assist in keeping the home environment clean. The registered manager acknowledged there was further work to do so that the checking systems captured areas for improvement and actions were planned and taken to make sure people consistently received high quality care.

This was an announced inspection. This was because we needed to make arrangements so that the provider was available and we could gain access to the home. Following our previous inspection on 1 November 2013 we imposed a condition upon the provider’s registration to restrict admissions to the home due to the concerns about the safety and suitability of the premises. This meant that there were no people living at the home at the time of this inspection.

The fire officer, contracts officer and health and safety officer from the local authority were present at the time of this inspection.

We talked with the provider, the home manager and the quality assurance and safety support manager about the improvements that had been made to the premises and facilities. We also looked at some quality checks and service histories that had been completed for the premises and equipment.

We considered all of the evidence that we had gathered under the outcome that we inspected around the suitability and the safety of the premises to answer one of the five questions we always ask;

Is the service safe?

We saw that the provider had carried out significant refurbishment and redecoration work at the home so that the premises and facilities were suitable and safe for people who come to live at the home. To ensure future repairs and improvements are completed we saw the introduction of monitoring and quality checks. We saw that the provider had introduced a responsive and planned approach to make sure that the premises and facilities were consistently developed, reviewed and improved as required to meet the needs and safety of people who come to live at the home.

We carried out this inspection due to the concerns that we had received from the local authority and other regulators.

At this inspection we did not speak with people who lived at the home as we wanted to be sensitive to their needs at this difficult time. However, we spoke with the manager, operations manager and some staff who worked at the home. The management team and the staff that we spoke with told us that people who lived at the home received care and support from staff that met their needs.

We spent time with the new staff member who had delegated responsibility for the maintenance of the home environment. They showed us the repair work that needed to be done. We saw that some of the work had been outstanding for a period of time. However we could not find a responsive and planned approach to get the repair work done that made sure The Hall Nursing Home was a suitable and safe place for people to live.

We also looked at the quality assurance arrangements the provider has in place to check the premises. We found that these did not effectively identify the shortfalls in all the maintenance work required to ensure that any work and repairs were dealt with in a responsive and timely way. This meant that the homes environment was not always consistently developed, reviewed and improved as needed to meet the needs and safety of the people who lived at the home.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still the Registered Manager on our register at the time.

We carried out this inspection because we had been made aware of concerns raised by the local authority and NHS professionals. The concerns were about the quality of care people received at the home to meet their health and care needs.

Some people who lived at the home were unable to communicate their experiences and views about the care they received due to their complex needs. Therefore we spent time at the home to watch to see how staff supported people. We also looked at a selection of care records for five people who lived at the home, and spoke with three members of staff and the management team which included the provider.

People that were able to speak with us were positive about the care and support provided. One person said: “If I need anything they (staff) will help me” and “I like it here, I have no complaints.” Another person said: “They (staff) always make sure I have drinks at hand in my room, I don’t even have to ask.”

We also spoke with some relatives and friends who visited the home. A relative said, “The staff are very particular about privacy and dignity. I think they’re (staff) remarkable” and “Recently I have seen activities getting better.”

We saw that staff were kind and caring in the way they supported people. Although staff were busy they took time to support people at their own pace with their daily routines. We saw examples where staff responded promptly to any requests for assistance and the ratios of staff were monitored to ensure this remained the case.

We observed the lunchtime and teatime meals. Overall there was a relaxed approach to mealtimes as we saw that people made choices what they would like to eat and where they would like to eat their meals. We also saw that hot and cold drinks were readily available for people throughout the day together with staff support where required.

People had a care plan that reflected their needs and their personal routines. We saw that staff got people’s consent before they delivered care. We also noticed work was on-going to protect people who were unable to give their consent so that this was accurately recorded in their care records for staff to follow.

Following our inspection on 3 December 2012, we made compliance actions as we had a number of concerns. These were mainly about the accuracy of reflecting people's needs within their care plans at all times. We also had concerns over cross infection risks to people living at the home due to staff practices. We had also issued a warning notice as we found that people were not fully protected against the unsafe use of medicines.

At this inspection we found that progress had been made in all the outcome areas where we had previously had concerns and improvements had been made.

Our inspection was unannounced; no one knew we would be visiting. We spoke with five people and five staff, the manager and operational manager to find out their views about the service provided at the home.

The people who lived at the home we talked with were happy with the quality of the care provided. One person said: "They (staff) help me and all do it with a smile".

People told us staff treated them with respect and dignity. One person told us: "They (staff) are all nice to me".

We looked at the medicine administration records for seven people and how the service stored and managed medicines. We found that arrangements were in place to ensure that medicines were managed safely.

There were processes in place to monitor risks to the quality and safety of care. There was evidence that learning from incidents took place and appropriate changes made.

At our last inspection in July 2012, we set compliance actions to address issues identified. These included the care and welfare of people living at the home, the management of staffing and monitoring of the care practices in the home.

During this inspection, we spoke with three people living at the home, the manager, the operational manager and five staff. Following our inspection we also spoke with four relatives.

We found that some improvements were being carried out that ensured people’s needs were being met with identified risks reduced.

We observed that staff spoke with people who lived at the home in a respectful way. People who lived at this home who we spoke with told us they were happy with the quality of care and support they received. One person said, “Food is okay” and “Staff are very good and caring.” This person also told us that there were activities if they wanted to join in these but liked to also spend time in their room which they said staff respected.

We found that the medicine administration, management and practices were not effective and therefore people were at risk from not receiving their medicines as prescribed.

In this report the name of two registered managers appear who were not in post and not managing the regulatory activities at this location at the time of the inspection. Their names appear because they were still Registered Managers on our register at the time.

The service and the people who used the service had experienced a lot of change in recent months. A new manager, a new regional manager and a new deputy manager had all commenced work with the service within a few weeks of our inspection. The new manager had been in post two weeks when we inspected.

Two activities coordinators were working for the service so that people were provided with social and recreational activities seven days a week.

One person who used the service and could mobilise with support was in bed when we inspected. When we spoke to the deputy manager later in the day they told us that that this person was supported to get up every day and they were surprised to find that they were still in bed. When we had spoken with this person earlier in the day they told us that they never got asked whether or not they wanted to take part in activities.

We sat with someone who was eating their lunch in their room. They had been given their main meal and their hot pudding at the same time. This person did not eat very much of their lunch and they told us that the main meal had gone cold and that the pudding was too dry to eat.

One person we spoke with had only used the service for a few months. They told us that they were “settled in now” and that they were “well looked after”.

We visited the service to see what improvements had been made since our last visit in August 2011. The visit took place over two days. Following our last visit the provider sent us an action plan to show us what they were going to do improve the service.

When we spoke with people who lived at the home they told us that they liked the lounges and enjoyed the meals.

Two people that we spoke with in the lounge told us they enjoyed that lounge as “it was quiet” and had “a lovely view to the garden”. Four people that we spoke with in another lounge told us they were watching the television and that later they had the choice of entertainment in the afternoon, but they did not always join in.

Three people we spoke with told us that they had preferred to stay in their rooms during the day and did not like to go to the communal areas of the home. Two people told us that they sometimes had to wait for care workers, but this was during “busy times” at lunchtime and in the morning.

The home employed three activities coordinators whose role was to arrange and engage people that lived at the home in activities. During the morning we observed that two activities coordinators were in the home. People were able to join in a balloon game, followed by a group card game, whilst others received hand and nail care in the quiet lounge. In the afternoon arrangements had been made for a singer to visit the home and provide entertainment. On the second day of our visit people had the option to play a game of bingo.

People we spoke with in the lounges told us that it was not always easy to get the attention of care workers unless they were in the room. The manager told us during our last visit that further call points were going to be installed in the communal areas to ensure people are able to call staff easily. The call bell in these rooms had one static call point and people who had lived at the home were not always able to independently reach this.

We looked at the care records for three people who used the service. There had been improvements to the information detailed about the clinical needs of the people who lived at the home. There were still areas for improvement so that care workers and nursing staff had clear information about how to meet those needs. People who lived at the home had little information recorded in their care plan documentation about their life and personal histories. There was no evidence of any involvement in their care plans. People had their preferred bed times, the time they liked to get up in the morning and their preference for receiving personal care from a male or female care worker recoded.

Following our visit in March 2011 a new manager had been appointed. When we visited this time we saw that staff were taking a more person centred approach to care. Staff were engaging and talking with people, and not just focusing on tasks. The manager had supported staff in making changes to ensure that people who lived there were treated as individuals.

Complaint and feedback forms were in the entrance hall and were available for people to use. All comments are looked at by the manager. The manager told us they were keen to listen and reflect on the needs of the people. They told us that following a recent residents and relative meeting they will be introducing a memory box for each person that lived at the home.

The people we spoke to told us that they were well looked after and the staff were kind and looked after their needs. They told us that they did not have to wait for things.

Staff were respectful to people and they offered support and encouragement when assisting people with a task or activity. During the morning we saw that people were playing skittles and throwing rings over a target in the garden. The home had a large activities room where we saw games and other equipment that people could have used.

The manager told us that the home is planning to have a fete in August to raise additional funds that will be used for more activities within the home.

We saw that people were supported to spend time in the garden, and were having an afternoon drink and snacks.

People we spoke to told us that they were happy with the care and activities provided and that the food was good, with large portions being served. One person told us that they did not like the attitude of the night care workers. Two relatives told us that the accommodation provided for their relative was good. They said that they felt that the care provided had improved over the last few weeks