Archived: St Georges Nursing Home

St George's Nursing Home provides accommodation and nursing care for up to 44 people. The service is located in three period town houses across five storeys, with a day room and two dining areas in the basement. At the time of our inspection there were 20 people using the service. Some of the people living at the home were living with dementia.

People’s experience of using this service and what we found

Since our last inspection the registered manager had worked hard to make many improvements such as medicines management, reviewing care and support documentation, policies and procedures and the overall management of the service. However, there was some work which was still outstanding such as staff training, building and maintenances issues. There were lots of improvements in quality assurance and monitoring. On the whole staff and relatives spoke positively of the progress made so far and staff in particular felt more supported.

The home followed good infection control practices. It was clean and tidy; a refurbishment programme was underway. There was outstanding building work since the last inspection that still needed urgent attention. We saw evidence of the registered manager trying to address these issues. We made a recommendation to the provider regarding repairs.

Medicines were managed safely. People were protected from abuse and were treated with care and respect. The registered manager had introduced training for all staff, but many staff had not completed the mandatory training. The registered manager was reviewing how training would be delivered to staff going forward. People spoke well of the service and they enjoyed living at the home. Since the last inspection the home had no safeguarding concerns and staff understood how to keep people safe.

Since the last inspection the registered manager had recruited one staff member and this was conducted in a safe way.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update.

We undertook this targeted inspection to check whether the provider had met the requirements of the Warning Notices in relation to regulations 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) 2014. The last rating for this service was requires improvement published 22 December 2020 and there were multiple breaches of regulation for safe care and treatment, staffing and good governance. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. This service has been rated requires improvement for the last six consecutive inspections. We will meet with the provider and continue to work alongside the provider and the local authority to monitor ongoing progress.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St George’s nursing home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.

St George's Nursing Home provides accommodation and nursing care to up to 44 people. The service is located in three period town houses across five storeys, with a day room and two dining areas in the basement. At the time of our inspection there were 21 people using the service.

People’s experience of using this service

We received very positive feedback about many aspects of the service from people’s relatives and visiting professionals. Remarks from people’s relatives included, “I’m so grateful [person] is so well cared for” and “This is so much better than were they were before.” A doctor said, “My patients have been happy, safe and kindly cared for.”

The home has made many improvements since the last inspection and has a detailed action plan in place. Staff and relatives spoke positively of the progress made so far. However, we found breaches related to recruitment and the management of the service. Staff had not always been safely recruited and managed. We found that we had not been notified of everything that we should have been.

The home followed good infection control practices. It was clean and tidy although there were areas needing urgent repair. These works had been quoted but not completed at the time of inspection.

We received good or excellent feedback about the home and the care people were given. People spoke highly of the food and the new chef told us the home was meeting people’s nutritional needs using good quality fresh food. The registered manager told us people were gaining weight and their health had improved because of the improvements to their diet.

People were safe and looked after by staff who cared for their wellbeing. The home had taken appropriate action in response to serious safeguarding incidents. Staff training in safeguarding had been refreshed and they told us they now better understood their responsibilities around whistleblowing when they had concerns about colleagues’ practice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 06 January 2020) and there were multiple breaches of regulations. The service remains rated requires improvement.

This service has been rated requires improvement for the last five consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 23 and 24 October 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the areas of safe care and treatment, staff training and recruitment, good governance and person-centred care.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions which contain those requirements.

The inspection was prompted in part due to concerns received about the management of the home. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those Key Questions not fully looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St George's Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to staff recruitment and the management of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St George’s Nursing Home provides accommodation and nursing care to up to 44 people. The service is located in three town houses across five storeys with a day room and two dining areas in the basement. At the time of our inspection there were 26 people using the service.

People’s experience of using this service

People were protected from abuse and told us they felt safe using the service. Risks to people's wellbeing were not always fully assessed and there were not always enough checks to make sure risk management measures were followed. Medicines were administered safely by competent staff but some aspects of storage were not safe and there were not always protocols for administering medicines. There were enough staff to support people safely but recruitment processes were not always fully followed. People were protected from cross infection.

Although the provider had assessed staff training needs these had not always been met and staff did not always have regular supervisions. People had the right support to eat and drink and the service worked with other agencies to help people maintain their health. The service continued to implement specialist advice on improving the accessibility of the building whilst maintaining a homely environment. The provider was meeting requirements to obtain consent to care and to assess people's capacity to make particular decisions.

People told us staff were kind and friendly and people were supported with their religious needs. People were able to make choices about how they received their care and to bring personal items and pets to the service. People told us they were treated with dignity and respect.

Some people told us they didn't get to choose when they got up and in some cases people’s nails were dirty. Reviewing of care plans was inconsistent and people were not always involved in this process. The service had an improved and varied activity plan and people had more meaningful activities and contact with the wider community. The provider responded appropriately to complaints and improved practice in response to these.

The management team had engaged well with the local authority and sources of expertise to develop and improve the service and understood where improvements were needed. There were improved audits of the service but these were not always comprehensive and effective. People spoke of an open and positive culture and improved morale among the team.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection:

The last rating for this service was requires improvement (published 24 October 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to safe care and treatment, staff training and recruitment, good governance and person centred care at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At our last inspection on 10 April 2018 we rated this service ‘inadequate’ and placed the service under special measures. We had found breaches of regulations concerning safeguarding adults, the recruitment of staff, management of medicines, training and supervision, person centred care, good governance and the management of complaints.

At this inspection we found significant improvements had taken place. The service was now meeting regulations. We have changed the rating to ‘requires improvement’.

St George’s Nursing Home is a care home with nursing. 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 service provides nursing care to up to 44 older people with some living with dementia or substance misuse issues. The provider was voluntarily not admitting new residents since our last inspection and there were 25 people using the service at the time of this inspection.

Since our last inspection the provider had appointed a senior manager and had worked with the local authority to bring about improvements. They were delivering an action plan which addressed our previous findings. There was a more open and creative culture amongst the staff team. Regular meetings were taking place with staff and the families of people who used the service and there were clearer systems of communication between staff and managers. There were processes to be followed for investigating and responding to complaints.

People had access to more interesting and varied activities designed for people living with dementia and a full-time activities co-ordinator was in place to continue to develop these. We observed positive interaction with people using the service.

The provider had changed their processes for the management of medicines. There were thorough checks carried out which meant people received their medicines safely. Safer recruitment processes were in place to ensure staff were suitable for their roles. The provider’s audits had shown that they did not always hold the correct information on staff members and this had not yet been fully addressed. There were suitable assessments of staffing levels and people told us there were enough staff to meet their needs.

Care workers and nurses were now receiving training and supervision, but had not yet received all the training they required. There was further training planned from credible sources to make sure staff continued to develop the right skills to carry out their roles. Managers received training in safeguarding adults to make sure they knew their responsibilities to report suspected abuse.

There were improved processes in place to monitor when incidents and accidents had occurred and how to learn from these. Infection control procedures had improved. Managers carried out detailed audits of all aspects of the service to identify areas for improvement and act upon these. The service was better organised in every respect.

The provider carried out detailed assessments of people’s needs, but sometimes these contained minor errors. Care plans met people’s needs and were reviewed regularly, but sometimes lacked person-centred details for people’s personal care. There was improved life story work and information about people’s wishes and preferences. There were measures to offer people choice on what they ate and drank and to protect against malnutrition.

The provider had taken advice on how to make the building more suitable for people living with dementia. We saw examples of how the provider had acted on this advice, such as improved signage, higher contrast toilet seats and staff wearing name badges. Aspects of the building’s design did not promote independence and managers told us they intended to develop this. There were processes in place to ensure the building was safe and kept in good repair.

Consent to care was obtained. People’s decision-making abilities were assessed in line with the Mental Capacity Act. Potentially restrictive measures were assessed to ensure deprivation of liberty safeguards were being followed. Care plans were in place which met people’s needs and were reviewed monthly. The provider was not meeting accessible information standards to provide information in a manner suitable for them. We have made a recommendation about this.

The service is no longer in special measures. We will continue working with the local authority and NHS to monitor this provider to ensure the improvement we observed continues. We will carry out a further comprehensive inspection within 12 months. We will return before this time if we think this improvement has not been sustained.

St George’s Nursing Home is a care home with nursing. 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. At the time of our inspection there were 32 people using the service, 20 of whom were living with dementia.

At our last inspection in August 2017, we rated this service ‘requires improvement’ overall and ‘inadequate’ in relation to safety. Breaches were found relating to safe care and treatment, safety of premises, medicines, training and supervision of staff, dignity and respect, consent to care, recruitment of staff and notification of significant events.

Following the last inspection, we asked the provider to complete an action to plan to show what they would do and by when to meet regulations. At this inspection we found the provider was meeting regulations relating to premises safety, dignity and respect and consent to care. However, there had not been satisfactory progress in addressing other areas where the provider had breached regulations and practice had declined in some areas. Consequently, we have rated this service ‘inadequate’.

This service put people at unacceptable risk of harm by failing to ensure the safe management of medicines. People missed their medicines or received the wrong dose or at the wrong time. There was a fundamental failure to implement a robust governance framework for delivering medicines safely and a failure by the provider to make sure staff had the right training to do this. Tablets were crushed without proper authorisation in a single crusher which was dirty and contaminated. There were some serious medicines errors, including one person who received an ear drop in their eye. The provider’s own records had shown 35 incidents, errors or discrepancies had taken place in just 13 weeks prior to this inspection; these had not been investigated or action taken to address the cause of the errors. The service was unable to account for some controlled drugs and had not disposed of these safely, contravening regulations relating to the misuse of drugs.

The provider did not operate safer recruitment processes as appropriate pre-employment checks had not been carried out. Staff continued to lack adequate training and supervision to carry out their roles. At times there were fewer staff than the provider told us would be in place; there had not been any assessments as to whether these staffing levels were adequate. We observed improved infection control measures, as the building was clean, but staff lacked formal training in this area.

Action had been taken to improve the safety of the premises. Risks to people were routinely assessed and management plans were in place to manage risks from choking and pressure sores. When incidents and accidents had occurred the provider failed to follow its policies and did not look into the causes or take action to prevent a recurrence.

The service lacked insight into the needs of people living with dementia. There was no dementia training made available to staff and a lack of meaningful activities suitable for people using the service. The building was not designed and laid out in a way that would enable people living with dementia to orientate themselves and maintain their independence. Consent to care was obtained, but the provider did not always assess people’s capacity to make specific decisions. We have made a recommendation about this.

People were monitored for the risk of malnutrition but food choices were not presented in a way which gave people living with dementia any meaningful choice. There were extremely limited systems for seeking people’s views on their care and acting on them. Complaints were not recorded or investigated in a way which facilitated a meaningful response.

People told us that staff were caring, but sometimes we observed less positive interactions. People took a long time to receive their food and were frequently left unattended. Care plans were not designed in a person centred fashion and were not set out in a way which meant people could understand their contents.

The management of the service was inadequate as the provider did not carry out the right checks to ensure that care was being delivered safely and effectively. The provider did not take action to address many of the concerns we highlighted in our previous report.

We found breaches of regulations concerning safeguarding adults, the recruitment of staff, management of medicines, training and supervision, person centred care, good governance and the management of complaints.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

St George’s Nursing Home provides accommodation and nursing care for up to 44 older people including people with dementia and substance abuse issues. At the time of our inspection there were 35 people using the service. Care is provided across several adjoined houses on St George’s Square in Pimlico. Facilities included a day room, dining room, library, a single lift, a small patio and chapel, and services include a launderette and kitchen.

The service is not required to have a registered manager, but had a registered provider who was the business owner and matron, who was the registered person for the service. 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 found that people who used the service and their relatives were positive about the service they received, including the quality of care and management. People told us that they felt respected and their privacy and dignity was maintained.

People’s privacy was not always respected, as CCTV cameras were operational in people’s rooms and there was a lack of clear guidance of its use, which meant that these were left switched on when people received intimate personal care. We issued a warning notice with regards to this following the first two days of our inspection, and the provider had taken action to address this by the final day of our inspection. Care workers were not consistently caring and respectful towards people, and there was limited use of tools to enable people to express their views about their care. Care plans were not always person centred, but care workers and managers demonstrated a good understanding of people’s needs and wishes. The provider obtained consent to care, but did not always assess people’s capacity or assess whether measures such as bedrails were restricting people’s liberty. There was not always consistent review of care plans, which were not always clear about people’s wishes for the end of their lives and for after their deaths. People received good support to eat and drink and to maintain good health, and were able to have pets living with them.

Aspects of the premises were not safe. We found that fire escapes were blocked and some fire doors did not close properly. This had been noted in health and safety checks but not always followed up. Similarly, gas and electrical safety checks had raised concerns about the safety of these systems, but the provider had not taken steps to ensure the building remained safe. We issued a warning notice with regards to the safety of the premises, which the provider took suitable action to address. We visited with the London Fire Brigade to verify that the service met fire safety regulations. The premises were not always suitably laid out to meet the needs of people with dementia, particularly with regards to how people orientated themselves in the building, but people and their relatives praised the homely feel of the building. We have made a recommendation about this.

There were good systems of communication and handover in place. Staff told us that they were well supported and received suitable training and supervision, and there was evidence that staff were able to develop in their roles. However, the provider lacked systems to record and audit staff training and supervision, and so could not demonstrate that this was up to date. The provider did not always obtain a detailed work history before people started work, but undertook checks to ensure that staff were suitable for their roles. The provider had risk management plans in place but these were not consistently reviewed. Medicines were safely managed and administered, but the provider did not check that these were stored at a safe temperature. Good infection control processes were not always followed, which included open bags of clinical waste being left in bathrooms.

Some key systems of audit were lacking, which included the auditing of staff recruitment, training and supervision and the checking of care plans. We found that turning charts were often incomplete and were not checked by senior staff. People were confident in making complaints, but we found that complaints were not always recorded in a way that ensured they were followed up and investigated. The provider did not notify the Care Quality Commission (CQC) of important events such as deaths of people using the service.

We have made recommendations about infection control and providing a more dementia friendly environment. We found breaches of regulations relating to safe care and treatment, storage of medicines, privacy and dignity, staff recruitment, training and supervision, notifications to CQC and good governance. We issued warning notices with regards to the safety of the premises and privacy and dignity. You can see what action we told the provider to take at the back of the full version of this report.

We saw that people were offered a choice of suitable and nutritious food and drink and were protected from the risks of inadequate nutrition and dehydration. There were effective systems in place to reduce the risk and spread of infection.

People who used the service, their representatives and staff were asked for their views about care and treatment and we saw that these were responded to. However, we found the provider did not fully support staff to deliver care and treatment safely because there were no formal supervision or appraisal processes, no clear record of training for each member of staff and insufficient training in the psychological aspects of care.