This inspection was carried out on the 5th and 7th June 2018 and was unannounced. St Johns Nursing Home is a 'care home'. People in care homes receive accommodation and nursing, or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home provides care and support to up to 58 older people who may have dementia. At the time of this inspection 46 people were using the service. At our last inspection of this service on 29 November 2016 the service was rated ‘good’.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk relating to people using the service. This inspection examined those risks.

At this inspection we found breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Appropriate action had not always been taken to support people where risks to them had been identified. Staff were not always supported in their roles through training and supervision. You can see what action we told the provider to take at the back of the full version of the report.’

We also found that appropriate health care professionals, the local authority and CQC had not been notified the in a timely manner of a recent incident of attempted self-harm. Although there were systems in place that complied with the Mental Capacity Act 2005 (MCA 2005) we found that Deprivation of Liberty Safeguards applications and conditions were not always managed appropriately. During our routine observations we found a number issues with maintenance at the home. The registered manager addressed the issues above during the inspection.

The home had 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 provider reviewed records of accidents and incidents to determine whether any changes were needed to the way in which people were supported, but improvement was required to ensure accidents and incidents were consistently reported to the appropriate authorities. People told us they felt safe living at the home. Training records confirmed that staff had received training on safeguarding and there was a whistle-blowing procedure available and staff said they would use it if they needed to. There was a good staff presence at the home and staff were attentive to people’s needs. Medicines were managed appropriately and people were receiving their medicines as prescribed by health care professionals. There were procedures and policies in place to protect people from the risk of infections and to ensure the home environment was kept clean.

Staff were aware of the importance of seeking consent from people when supporting them with their needs. Assessments of people’s care and support needs were carried out before they moved into the home. Most people told us they enjoyed the meals provided to them and they could choose what they wanted to eat. People were supported to maintain good health and they had access to healthcare professionals when they needed them.

People had been consulted about their care and support needs. Care plans and risk assessments included detailed information and guidance for staff about how people’s needs should be met. People told us their privacy and dignity was respected. There were plenty of appropriate activities for people to partake in if they wished to do so.

This inspection was carried out on 19 October 2016. The inspection was unannounced.

We previously carried out an unannounced comprehensive inspection of this service in November 2014. Breaches of legal requirements were found because records relating to people’s mental capacity were not always completed or clear, the procedures in place to ensure people received their medicines safely were not always appropriate and staff training was not up to date.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements. We undertook a focused inspection in June 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

During this inspection we found the provider was meeting the regulations.

St Johns Nursing Home provides nursing and personal care for up to 58 people. At the time of our inspection there were 39 elderly people living in the home some of whom were living with dementia.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People told us they were felt safe from abuse. Care was planned and delivered to ensure people were protected against abuse and avoidable harm. There was a sufficient number of suitable staff to help keep people safe and meet their needs. Staff had been recruited using a thorough recruitment process which was consistently applied. Appropriate checks were carried out before staff were allowed to work with people.

People’s medicines were appropriately managed so they received them safely. Staff understood their responsibilities in relation to infection control. People were protected from the risk and spread of infection because staff followed the procedures in place. The home was clean and well maintained.

People were cared for by management and staff who had the necessary experience and knowledge to support them to have a good quality of life. Staff had received relevant training and were supported to obtain further qualifications relevant to their roles. Staff understood the relevant requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) and how it applied to people in their care.

Staff enjoyed working with the people in their care. People were treated with respect, compassion and kindness. They were fully involved in making decisions about their care including what they ate and how they spent their time day-to-day. Where appropriate their relatives were also involved. The management and staff knew people well. They knew their routines and preferences and understood what was important to them. People were supported to express their views and give feedback on the care they received.

Staff knew what constituted a balanced diet. People were given a choice of nutritious meals and had enough to eat and drink. People received the help they needed to maintain good health and had access to a variety of healthcare professionals.

People were supported to maintain their independence and avoid social isolation. People were supported to participate in a variety of activities inside the home and attend organised trips outside the home. Relatives were made to feel welcome and were regularly consulted about how people were supported.

The registered manager had worked in adult social care for many years and understood what was necessary to provide quality care. The home was well organised and managed. People's records including their medical records were fully completed and up to date. There were a variety of systems in place to regularly check and monitor the quality of care people received.

We carried out an unannounced comprehensive inspection of this service on 26 & 27 November 2014. Breaches of legal requirements were found. This was because records relating to people’s mental capacity were not always completed or clear. We did not see why decisions had been made and why it was in the person’s best interests to make these decisions. Some people who lacked capacity received covert medicine. Covert is the term used when medicine is administered in a disguised way without the knowledge or consent of the person receiving them. When we looked at people’s care records we did not always see that a mental capacity assessment had been completed in respect of people’s covert medicines. Staff clearly explained how they gave people their covert medication, but we did not find this guidance recorded in people’s care records. Staff told us they had consulted with the pharmacist for their advice and agreement but this was not always recorded. Recording this information was necessary because adding certain medicines to food or drink can alter the way they work or how they affect people.

We also were concerned that not all staff had completed their refresher mandatory training and some staff may not have had the appropriate training or skills to deliver safe and appropriate care to people.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 9 June 2015 to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘St Johns Nursing Home Ltd’ on our website at www.cqc.org.uk.

St Johns Nursing Home provides nursing care and support for up to 45 older people, some of whom are living with dementia. The service had a registered manager and they had been in post since 2007. 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 focused inspection on 9 June 2015, we found that the provider had followed their plan and legal requirements had been met.

People identified as requiring covert medicine now had written information in their care records giving details about why this decision had been made, what needed to be considered for example could any other less restrictive action be taken, how the medicine should be given safely and who was involved in the decision making process for example the GP, the lead nurse and pharmacist.

Improvements had been made in staff training and most staff had received some refresher training since our last inspection. A schedule of training was due to be finished by the end of the summer 2015 as some staff still needed to complete their mandatory training. The manager was working on ways to identify staff training needs and keep staff training up to date in the future. We will look at staff training again in detail during our next inspection.

We spoke with the registered manager, deputy manager a nurse and three care workers. We also spoke with three people and three relatives.

One person said “the home is marvellous, staff do everything to help and I am not afraid to ask.” A second person said they thought “the staff are good.” A third person said it is a “lovely place to live” and they were, “happy in the home.” One relative said “it is not five star accommodation, but the care is.”

The atmosphere was friendly and relaxed on the day of inspection. We saw people engaged in colouring pictures and they were supported by staff. We saw that hairdressing services were available on the day of inspection.

We observed that staff respected and involved people in their care. People received the care and support that met their needs. We saw that the home met people’s nutritional needs. We observed that staff were properly trained and adequately supported. We saw that people were protected against the risk of unsafe equipment. The provider assessed and monitored the quality of care that people received.

We spoke with eight people who use the service, seven relatives, six members of staff, the manager and the provider during this unannounced inspection.

People who use the service said "it's smashing", "I have the best view in the house", "the care is good but I get frustrated when staff don’t understand me", “the quality of care is fine” and “its ok here".

Most people made positive comments about the food saying "good", "always two choices", "I choose to eat in my room" and "they give me the help I need" although we saw that people who needed their food pureed did not get a choice of meal.

Comments about staff included “extremely nice”, "kind, caring and wonderful", "staff who take care of you are cheerful”, "staff are ok, some aren’t but you get that everywhere”, "they come when I call" and "staff give me the help I need and want".

Relatives we spoke with were happy with the care and support provided saying that they were kept informed of any changes and made to feel welcome when they visited. People we spoke with had not made a complaint but would speak to the manager or staff if they did. Relatives said people had plenty of opportunities for activities and outings.

Staff we spoke with said that there were enough staff to meet people's needs. We saw one floor where staff were busy and people could have had more to do, although some people had gone out for lunch which meant the activities staff were not available to help as they usually did.

People told us staff respect their privacy and dignity and are available to help when needed. People are happy with the activities they can join in and enjoy the food. Relatives are happy with the care and support provided and made positive comments about staff.

St Johns Nursing Home provides nursing care and support for up to 45 older people, some of whom are living with dementia.

Our inspection took place on 26 and 27 November 2014 and was unannounced. At our last inspection in October 2013 the service was meeting the regulations inspected.

The service had a registered manager and they had been in post since 2011. 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.

People and their relatives told us they felt safe at the service. Staff knew how to recognise signs of potential abuse and followed the right reporting procedures. Staff positively supported people when their behaviour challenged the service and clear guidance was written for them in people’s care records. Staff made sure people were safe by identifying and taking steps to reduce risks.

People had access to healthcare services when they needed it and received on-going healthcare support from GPs and other healthcare professionals

Staff communicated with people in a kind and sensitive way. They were attentive while supporting people at mealtimes to ensure people had sufficient amounts to eat and drink. People and their relatives were positive about the food at St Johns Nursing Home and the ways in which the service involved people to make choices about the daily menu. Special dietary requirements were catered for and people’s nutritional risks was assessed and monitored.

During our inspection we observed that staff were caring. They showed people dignity and respect and had a good understanding of individual needs. There were lots of different activities for people to be involved in and we heard about ways the service tried to involve everyone in activities to stop people from feeling lonely or isolated.

The service was accredited with the Gold Standards Framework (GSF) for end of life care which ensured staff were trained to provide appropriate care, in accordance with people’s wishes, when they were nearing the end of their life.

People and staff were asked for their views on how to improve the service. Staff felt listened to and supported by their manager.

The provider had a number of audits and quality assurance systems to help them understand the quality of the care and support people received. Accidents and incidents were reported and examined. The manager and staff used information about quality of the service and incidents to improve the service.

Staffing was managed flexibly in order to support the needs of people using the service so that they received care and support when needed. However, not all staff had received the training or skills they needed to deliver safe and appropriate care to people.

People received their prescribed medicines at the right times, these were stored securely and administered by registered nurses. We found some records that related to people who took their medicines covertly were not always complete.

The provider was aware of the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) that ensured people’s rights were protected. However, we found mental capacity assessments were incomplete and did not find any details recorded about how decisions were made in people’s best interests. We have asked the provider to make improvements in the above areas.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

We have recommended that the provider consults the NICE Guidance on Managing Covert Medicines in Care Homes.