St Teresa’s 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 is registered to provide nursing and personal care for up to 70 older people accommodating people across three separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of the inspection 59 people were living at the service.

The inspection took place on 24 and 25 July 2018. The first day was unannounced.

At the previous inspection on 09 June 2016 we found improvements were required in recording the effectiveness of pain relief, pressure relieving mattresses, people’s dietary requirements and pressure ulcer dressing changes. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found some improvements had been made; however shortfalls still remained in relation to food and drink monitoring. This was because fluid intake targets had been calculated incorrectly. Charts we looked at did not show that people had enough to drink. Food monitoring charts did not detail what people had eaten. This meant staff would be unable to assess if people had received a nutritionally balanced diet. Other monitoring charts, such as position change charts had not always been completed in full.

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.

Quality assurance systems did not always identify shortfalls found during this inspection. There were extensive quality assurance systems in place; however, the inaccurate monitoring of people’s fluid intake targets had not been identified during audits. Actions arising from audits had not always been completed within specified timeframes. Shortfalls such as recording of complaints and statutory notifications had not been consistently completed.

Staff had been trained to keep people safe. People using the service and their relatives told us they felt safe. Care plans contained risk assessments. When risks were identified the plans provided clear guidance for staff on how to reduce the risk of harm to people.

Incidents and accidents were reported and analysed to identify trends. There was evidence that lessons were learned when incidents happened.

Medicines were managed safely.

Comprehensive pre-assessments had been completed before people moved to the service.

Staff were trained to undertake their roles. Staff had regular supervisions with a supervisor.

People using the service spoke highly of the staff and all were happy with the support they received. We observed positive interactions between staff and people.

Care plans were person centred; however, end of life plans did not always reflect people’s choices and preferences.

Air mattress checks were in place and all of the mattresses we looked at were set correctly.

Complaints were logged. However, investigations and outcomes of complaints had not always been documented.

We received mixed feedback from people using the service about the activities available to them and the level of social interaction they received.

All of the staff told us the service was well managed. People using the service and their relatives gave positive feedback about the management team.

Although the majority of statutory notifications had been sent to the commission, one incident in relation to an allegation of verbal abuse had not.

We found one breach of the Regulations in the Health and S

The inspection took place on 8 and 9 June 2016 and was unannounced. The care home was last inspected on 5 and 12 March 2015. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at that inspection. The breaches related to consent to care and the monitoring of care interventions. At this inspection we found actions had been taken to meet these regulations.

St Teresa’s Nursing Home is registered to provide nursing and personal care for up to 70 people. There were 68 people living in the home on the days of our visit. The home is divided into two units. The Gainsborough Unit accommodates up to 27 people, most of who are living with dementia. The Bartelt Unit accommodates up to 43 people who need general nursing care.

A third unit is currently being developed within the Bartelt Unit. This is called Austin Unit, and will provide accommodation for people living with dementia. The total number of people accommodated will not change.

There was a manager in post. They had applied and were in the process of completing the registered manager application process. 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 were assessed before they moved into the home to ensure their needs could be met.

Risks to people were assessed, and where identified, actions were taken to reduce the risks and keep people safe.

When we inspected on 5 and 12 March 2015 we found intervention charts such as fluid monitoring and positional change charts were not always completed. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found sufficient improvements had been made.

We found improvements were required in recording the effectiveness of pain relief, pressure relieving mattress settings, people’s dietary requirements and pressure ulcer dressing changes.

People told us they experienced difficulties in their communication with some staff that were not able to communicate effectively because of their English language skills.

People received personalised care that was responsive to their needs. Care plans reflected that people’s individual needs, preferences and choices had been considered.

People were supported to have their nutritional needs met. The dining experience was relaxed, and people received the support they needed.

Governance systems were in place to monitor and mitigate the risks relating to the health, safety and welfare of people.

When we inspected on 5 and 12 March 2015 we found systems were not in place to obtain consent from people. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found improvements had been made. We found the rights of people who did not have the capacity to consent to care and treatment were protected because the service worked in accordance with the Mental Capacity Act 2005.

The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. Where people were deprived of their liberty this was done lawfully.

People who were supported by the service felt safe. Staff understood how to safeguard people, and knew the actions they would take if they suspected abuse.

We found one breach of the Health and Social Care Act 2008 Regulated Activities) Regulations 2014.

Two inspectors carried out this inspection. We looked to see if improvements identified in a previous inspection had been met. This was in relation to outcome two, consent to care and welfare. We also looked at additional concerns which had been raised. This was regarding a fall in staffing levels and people not receiving the care as given in their care plan.

The focus of the inspection was to answer five key questions; is the service caring, responsive, safe, effective and well-led?

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

If you would like to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service caring?

People looked well cared for. When we spoke with people they were complimentary about the care they received from staff, describing them as 'caring' and 'friendly'.

Staff respected people’s privacy and were knowledgeable about the people they cared for. Staff were able to tell us about the people they supported, their likes and dislikes and their preferred care routines. One relative told us that they were very happy with the care their family member received. Prior to our inspection we had received information of concern in relation to people not receiving care as given in their care plan. We found this concern was unsubstantiated. We followed the care routines of six people and found that each person had received the care documented within their care plan.

Is the service responsive?

The home provided services for people with varying levels of need and records clearly demonstrated how care and support should be provided in line with people's wishes. There was a system in place to review the dependency needs of people and to change the level of support where required. Nursing staff reviewed and monitored people's care and treatment needs to ensure appropriate care was given in response to changing needs.

People's care and treatment was reviewed on a regular basis with them, this enabled people to discuss any changes or preferences regarding their care and support.

In the Gainsborough wing, people took part in activities if they wished to. In the Bartelt wing, the new activities co-ordinator was consulting with people about the activities they wanted to take part in. People told us they looked forward to this.

We found that there was a difference in the understanding and practice of some care workers in how they communicated with people. This particularly applied to those people who had a dementia or cognitive impairment and resulted in an inconsistent approach in how staff informed, involved and supported people with their care and treatment.

Is the service safe?

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found there were appropriate policies and procedures in place and staff we spoke with were confident of how the Mental Capacity Act 2005 and DoLS impacted on the people they supported. The provider had appropriate systems in place to ensure that best interest decisions were made in line with Regulation 4 of the Mental Capacity Act.

Quality audits were carried out to ensure a safe environment. The home was clean throughout and walkways were clutter free which enabled people to move around the home safely and freely. Medicine audits were undertaken to monitor and reduce potential risks. Incidents and accidents were responded to appropriately and the provider submitted notifications to the Care Quality Commission as required and reported relevant safeguarding concerns to the appropriate authorities.

Prior to this inspection we received information of concern around insufficient staffing. We did not find this to be the case. We found there were appropriate numbers of staff on duty to ensure that people received care in a timely manner.

Is the service effective?

The home had systems in place to ensure that people received the care they required. Care plans were person centred and demonstrated that people's care and treatment needs had been assessed and were reviewed on a regular basis. The nursing staff worked closely with other care staff in providing guidance when care and support needs changed which ensured a continuity of care.

People said they were happy that they received appropriate care and support. All care staff within the home were being offered specific training which was relevant to their role, such as dementia awareness.

Is the service well-led?

There were quality assurance processes in place which were monitored externally through the provider. There were audits in place and checks were made regarding the environment, record keeping, infection control, medicines, falls risks and complaints.

People told us they would inform the manager if they had any complaints. One person said "I have no complaints at all". There was a clear procedure in place where people or their families could raise concerns and information was available to people regarding the complaint process.

People were asked for their opinion on the service they received through satisfaction questionnaires. Staff were able to discuss concerns directly with the manager or through team meetings. Staff were aware of the structures in place regarding accountability and were confident in their role and responsibilities.

We spoke to seven people who use the service, seven members of their family and eight members of St Teresa’s staff.

People who use the service and their families said that privacy, dignity and independence were respected and their views and experiences were taken into account in the way the service was provided. One person said, “Everything is alright, I have no complaints”.

In addition people also expressed the view that before they received any care or treatment they were asked for their consent and St Teresa’s staff acted in accordance with their wishes.

People said that care and treatment was planned and delivered in a way that ensured safety and welfare. A relative said, “I think it’s excellent, it’s really good”. They said staff members noticed any little changes in the person’s behaviour or condition.

People we spoke to all informed us that a choice of meals was always offered and expressed a high level of satisfaction to us with the food provided at St Teresa’s; that it was nutritional and plentiful.

In the sample of records we checked, we did not find that the care plans for people who lacked the capacity to consent to them, were accompanied by a best interest decision which adhered fully to the requirements of the Mental Capacity Act.

One family member said, “I think this is a very good nursing home; the care is excellent; there is care and compassion”.

We visited St Teresa's Nursing Home on 1 October 2012 to follow up on some areas for improvement identified at our inspection in April 2012. On this follow-up visit we spoke with two people living at the nursing home and one visitor. The people we met said "this is a wonderful place" and "I am really very happy here". We were told "the staff are wonderful" and "I could not ask for a nicer place". The visitor we talked with told us the home was "wonderful" and "could not be better".

During our visit we spoke with some relatives who told us that they were pleased with the care that their relative received. They said “the staff discussed mum's needs with us and explained the care which they would be providing to help her”. People that we spoke with told us they felt the staff were “very kind, but they are busy". "I feel that the nurses have a good knowledge to care for us. The cleaners come in regularly and are very good”. One person told us: “There has been a new GP and he came round to say hello to everyone which was nice”. Also, "the staff are helpful and will do anything for you, they come quickly when you ring the bell". We saw that many of the people using the service had items of their own furniture in their rooms. Staff told us that this improved peoples' experience having familiar items and made the rooms personalised. People who use the service understood the care and treatment choices available to them

We carried out an unannounced inspection of St Teresa's Nursing Home on the 5 and 12 March 2015. At the last inspection we found there were breaches of legal requirements of previous Regulations. Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2010. The provider said they would take action to address the concerns by 30 November 2014. At this inspection we found there had been some improvements in the way staff built relationships with people.

St Teresa's Nursing Home is registered for a maximum of 70 older people. The home is divided into two units. The Gainsborough Unit accommodates up to 27 people many of whom are living with dementia. The Bartelt Unit accommodates up to 43 people who need general nursing care.

A  registered manager was not in post. The area manager and clinical lead had taken over the role of day to day management of the home. 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.

Staff told us there was an induction for new staff but shadowing of experienced staff  was not in place for all staff. Staff said they attended training which included safeguarding adults from abuse, dementia awareness and moving and handling. One to one and group meetings were taking place but not all staff had attended these meetings. This meant some staff did not benefit from this support or have the opportunity to discuss things such as career development. We have made a recommendation for staff to receive appropriate support  to enable them to carry out the duties they were employed to perform.

People told us they were not able to communicate with some staff. They told us some staff were not able to communicate effectively because of their English Language skills.

Staff had a good understanding of helping people make day to day decisions. Mental Capacity Act (MCA) assessments were not undertaken to assess people’s capacity to make decisions. This meant staff were not fully aware of the decisions people were able to make or the help they needed to make other  decisions.

People’s needs were assessed and care plans were in place, but these did not always accurately reflect the care and support given or required. Some plans and assessment had not been regularly evaluated. Records of interventions such as positional changes and food and fluid charts were not always being kept or were incomplete.

People and staff told us there was sufficient staff but there were vacancies for activities coordinators. There was a lack of support with regard to meaningful activity and social interaction for those people living with dementia.Relatives told us the staffing levels had improved with the recruitment of more staff.

People told us they felt safe living at the home and the staff treated them well. Members of staff knew the types of abuse and the actions they must to take for suspected abuse.

Risks were assessed and risk assessments were devised to reduce the level of risk. Assessments for people at risk of developing pressure damage and malnutrition were in place. Environmental risk assessments included fire risk assessments which assessed the potential of a fire in the premises. Individual emergency plans gave staff direction on the support people needed in the event the building needed to be evacuated.

People's medicines were managed safely and they had access to social and healthcare professionals.

Staff had developed positive caring relationships with people living in the home. They made efforts to respect people’s privacy and dignity. People were helped to eat their meals and their dietary requirements were catered for.

People told us their views about the home were sought and they gave positive feedback about the home. Staff described the culture of the home and that there was a “caring” culture. Staff told us the management of the home had improved and the area manager said the focus was to provide stability for staff to concentrate on the culture.

Audits and quality monitoring checks were taking place to ensure people’s needs were met and to assess the standards of quality were being met. Action plans were developed to ensure people’s needs and standards were fully met.

We found breaches of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulations 11 and 12 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