• Care Home
  • Care home

St Georges Court Care Home

Overall: Inadequate read more about inspection ratings

Russell Street, Cambridge, Cambridgeshire, CB2 1HT (01223) 712135

Provided and run by:
St. Georges Court Healthcare Limited

All Inspections

28 June 2023

During a routine inspection

About the service

St Georges Court Care Home is a ‘care home’ providing personal and nursing care to up to 76 older people. At the time of our inspection there were 67 people using the service, some of whom were living with dementia. The service has 3 floors and has its own adapted facilities and shared areas for people to use.

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

The provider’s quality monitoring systems had failed to identify that safeguarding processes were not always followed by staff to keep people safe from poor care. Staff had training but they did not always have the skills and knowledge to promote people’s nursing needs, health and well-being. Risks to people were not always considered. People’s care plans and risk assessments were not updated quickly enough when there were changes in people’s needs, nor did they always contain enough information to guide staff to support people effectively and safely.

Checks for medical devices were not always being completed in line with the manufacturer's directions. Medicines were not always managed safely, and people’s privacy and dignity was not always promoted by staff. Lessons were not always learnt. Internal investigations into incidents and accidents failed to identify outcomes, actions and learning to help reduce the risk of harm to people’s well-being.

Clinical areas within the service were not always kept clean to promote good infection control practices. Areas of flooring throughout the service were cracked and damaged. This included the laundry room. This meant that the cleaning of these areas to promote good infection control would be more difficult. The layout of furniture and furnishings of the floor that housed people, including people with complex dementia and nursing needs, was not conducive to supporting people who may be noise sensitive. The registered manager told us they wanted to put specialist signage in the service. This would help people who were sensory impaired or were living with dementia find it easier to orientate themselves around the building.

The provider’s governance, systems and audit processes were not robust enough. This was recognised by the provider's senior leadership team who told us they were committed to making and sustaining ongoing improvements required. The registered manager and the provider’s senior leadership team were responsive to our feedback and engaged with the CQC inspection team fully during the inspection process.

Despite our inspection findings people and their relatives told us they and their family member felt safe at the service. Whilst we observed missed opportunities for staff to meaningfully engage with people, we also saw some kind and considered interactions.

People's needs were assessed prior to them moving into the service. However, people, and their relatives, gave mixed feedback for their involvement in the care planning process. Activities happened at the service, however people living with dementia were not always given enough stimulation to help them spend their day meaningfully. Staff reacted to people’s anxieties rather than being proactive to try to reduce the number of incidents that occurred.

People, and their relatives told us they knew how to raise a complaint. However, verbal complaints were not always formally documented by staff.

The provider undertook safe recruitment procedures. Staff supported people in the main to receive a balanced diet and have enough to drink. However, people’s care records contained conflicting information to guide staff. People and their relatives had mixed opinions on whether they were involved in care decisions and reviews.

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.

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 good (report published 16 December 2017).

Why we inspected

The inspection was prompted in part due to concerns received by the CQC about safe care and treatment, safeguarding, infection prevention and control, promoting dignity, safe medicines management, and good governance.

We found evidence during this inspection that people were at risk of harm from these concerns. Please see the safe, effective, caring, responsive and well-led sections of this full report.

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.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding people from abuse, person-centred care, suitably skilled staff, promoting people’s dignity and respect, safe care and treatment, premises and equipment, and good governance at this inspection.

We wrote to the provider during our inspection due to our extensive concerns of people receiving poor quality care. The provider told us they had not been aware of the significant failings at the service and risks posed to people's safety and well-being. The provider submitted a robust action plan to the CQC in response to those concerns.

We have made a recommendation for the provider to review the accessible information available for people. We have also recommended the provider reviews the UK resuscitation council guidelines regarding end of life care information to guide staff.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

4 February 2021

During an inspection looking at part of the service

St Georges Court Care Home is a care home with nursing, which accommodates up to 76 older people, some of whom live with dementia. There were 65 people living at the service when we visited.

We found the following examples of good practice.

Staff made sure that people were protected against the transmission of infection from visitors by scheduling visits, limiting areas that visitors could access and being available to escort visitors.

Staff put appropriate actions into place to make sure people were admitted safely into the service.

Staff had enough personal protective equipment, such as masks, gloves and aprons, and had supported people so that they also understood the need for this.

Regular COVID-19 testing was carried out to make sure people and staff were safe.

The home was clean and staff had increased cleaning of frequently touched surfaces to reduce the risk of transmission of infection.

The provider made sure staff and the registered manager received enough support during the pandemic and when additional staff were needed.

There was COVID-19 specific policies and plans, which meant staff were guided to take appropriate actions to reduce the risk of transmission.

5 October 2017

During a routine inspection

St Georges Court Care Centre provides accommodation and personal care for up to 76 older people, some of whom may live with dementia. There were 65 people living at the home at the time of our visit. The home is a purpose built care home and is located close to the centre of Cambridge.

At the last inspection, the service was rated Good. At this inspection we found the service remained Good.

There was a registered manager in post at the time of our visit. 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 knew how to respond to possible abuse and how to reduce risks to people. There were enough staff who had been recruited properly to make sure they were suitable to work with people. Medicines were stored and administered safely.

People were cared for by staff who had received the appropriate training and had the skills and support to carry out their roles. Staff members understood and complied with the principles of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People received a choice of meals, which they liked, and staff supported them to eat and drink. They were referred to health care professionals as needed and staff followed the advice professionals gave them.

Staff were caring, kind and treated people with respect. People were listened to and were involved in their care and what they did on a day to day basis. People’s right to privacy was maintained by the actions and care given by staff members.

People’s personal and health care needs were met and care records guided staff in how to do this. There was a variety of activities for people to do and take part in during the day, and people had enough social stimulation. Complaints were investigated and responded to and people knew who to speak with if they had concerns.

Staff worked well together and felt supported by the management team. The monitoring process looked at systems throughout the home, identified issues and staff took the appropriate action to resolve these.

Further information is in the detailed findings below.

9 December 2016

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection of this service on 14 September 2015 and rated the service as good in all areas. After that inspection we received concerns in relation to people’s safety. As a result we undertook a focused inspection to look into those concerns. 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 George’s Court Care Centre on our website at www.cqc.org.uk”

This unannounced inspection took place on 9 December 2016.

Although appropriate action had been taken when any safeguarding concerns had been raised these had not always been reported to the Commission as required.

There was a staffing tool in place to calculate how many staff were needed to meet people’s needs. The staffing levels were sufficient to meet people’s basic needs. Extra staffing was sometimes required to support people when they displayed behaviour that challenged others. The registered manager had arranged for the extra staffing to be in place. The staff were not always aware of where people were and this could place them at risk.

Staff had access to personal protective equipment. This helped to decrease the risk of the spread of infection. People’s air mattress were regularly checked to ensure they were set at the appropriate levels to prevent them developing pressure sores.

14 September 2015

During a routine inspection

St Georges Court Care Centre is registered to provide accommodation and nursing care for up to 76 people. There were 72 people living in the home at the time of the inspection. Accommodation is provided over three floors.

This unannounced inspection took place on 14 September 2015. The previous inspection was undertaken on 27 April 2015 and we found that that the provider had taken action to meet the legal requirements in relation to care and support that people needed. During a previous inspection in January 2015 we found that improvements were needed regarding how the provider assessed and monitored the service they were providing. We didn’t inspect this at the April inspection because we wanted to see if the improvements made could be sustained for a longer period. During this inspection we found that the provider had made the necessary improvements and that the legal requirements had been met.

At the time of the inspection there was not a registered manager in place. However the manager had applied to the Care Quality Commission to be registered. The application was being processed by the Commission. 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 felt safe and staff knew what actions to take if they thought that anyone had been harmed in any way. There were procedures in place which were being followed by staff to ensure that people received their medication as prescribed. Risk assessments had been completed to identify and reduce risks to people where possible.

The requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) were being followed. This meant that where people were being restricted from leaving the home on their own to ensure their safety, this had been done in line with the legal requirements.

Staff had only been employed after a through recruitment procedure had been followed. There were enough staff available to meet people’s needs. Staff received the support and training they needed to carry out their roles effectively.

Staff were kind and compassionate when working with people. They knew people well and were aware of their life history, preferences, and their likes and dislikes. People’s privacy and dignity were upheld.

Staff monitored people’s health and welfare needs and acted on issues identified. People had been referred to healthcare professionals when needed.

People were provided with a choice of food and drink that they enjoyed.

There was a complaints procedure in place and people felt confident to raise any concerns either with the staff or the registered manager.

The manager obtained the views from people that lived in the home, their relatives and staff about the quality of the service and action taken if any improvements were needed.

27 April 2015

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection of this service on 12/13 January 2015 . Breaches of legal requirements were found and we served a warning notice. This was because people did not always receive the support with their health care needs that they required. 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 this focused inspection 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 those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Georges Court Care Centre on our website at www.cqc.org.uk

St George's Court Care Centre is a care home with nursing which provides a service for up to 76 people over three floors. At the time of our inspection there were 57 people living in the home.

A registered manager was not in post at the time of the 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.

At our focused inspection on the 27 April 2015, we found that the provider had followed their plan which they had told us would be completed by the 11 March 2015 and legal requirements had been met.

People told us and we saw that they had received the support they required with their wound management, pressure area care and diabetes monitoring . The staff on duty knew the people they were supporting and demonstrated their knowledge about supporting people with changing their dressings and how often this should be completed. They were also aware of how people with diabetes needed to be monitored.

Staff had received additional training in relation to supporting people with pressure area care, wound management and diabetes.

12/13 January 2015

During a routine inspection

St Georges Court Care Centre is a care home with nursing which provides a service for up to 76 people over three floors. At the time of our inspection there were 66 people living in the home.

This unannounced inspection took place on 12 and 13 January 2015. The previous inspection was undertaken on 25 and 26 June 2014. During the inspection of 25 and 26 June 2014 we found that three regulations were not being met. We received an action plan that stated the required improvements would be completed by 31 August 2014. We required the provider to make improvements to ensure that people’s legal rights were upheld regarding making decisions about their care and welfare. We found that this action had been completed. We also required that improvements were made to ensure that each person had their individual needs assessed and planned for and that care was delivered in a way that met people’s needs. We found that the necessary improvements had not been made in all areas of people’s care. We also required that improvements were made regarding keeping accurate records. We found that this improvement had not been made in all areas of people’s care.

At the time of this inspection there was no registered manager in place. However, the current manager was in the process of applying to become 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.

Although people’s healthcare needs were monitored the issues weren’t always consistently acted upon in a timely manner. For example, although staff were aware that some people needed to have their dressings changed this wasn’t always completed when it should have been. This meant that people were at risk of receiving care or support that could put their health and welfare at risk. Care plans and records did not always contain all of the information that staff required so that they knew how to meet people’s needs in a consistent manner. We also found that staff did not always follow care plans so that people received care in the manner that they preferred. For example, the care plan for one person stated that staff should assist them with nail care daily. However we found during the inspection that this had not be carried out.

The provider had quality assurance processes and procedures in place to improve, if needed, the quality and safety of people’s support and care. However, the provider had not identified the issues we found during our inspection and this placed people at risk of receiving inappropriate care.

People felt safe living at the home and staff were aware of the procedures to follow if they suspected anyone was at risk of harm. There were a sufficient number of staff employed at the home. However, there were sometimes delays of people receiving the care they needed. People received their correct medication on time by trained staff.

Staff were only employed after a thorough recruitment process had been undertaken. Staff received an induction which included training and shadowing experienced members of staff. Staff felt supported and could discuss any concerns they may have had with a member of the management team.

People were provided with adequate amounts of food and drink to meet their individual likes and nutritional and hydration needs.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. Action had been taken to ensure that if people did not have the capacity to make decisions then these were made in their best interests and in line with the legislation.

People’s privacy and dignity were respected and care was mainly provided in a caring and compassionate way.

We found a number of 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 the report.

25, 26 June 2014

During a routine inspection

Two inspectors carried out this inspection. The focus of the inspection was to answer the five key questions we always ask:

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at. If you would like to see the evidence that supports the summary, please read the full report.

We used a number of different methods to help us understand the experiences of people using the service. Some of the people had complex needs which meant they were not all able to tell us about their experiences. However, we observed the care being provided and spoke with eight people. We also spoke with, or received information from, two relatives, a GP who visited the home regularly, and 11 staff including two nurses, the manager of the home and two other managers who have line management responsibility for the home. We looked at staff training records, the provider's audits and five people's care records.

Is the service safe?

We found that each person had a care plan and associated risk assessments in place. However, we found that care plans had not all been updated to reflect the care being provided to people. We also found gaps in the recording of the daily care delivery. This was particularly in relation to records of people's food and fluid intake, repositioning to prevent pressure ulcers developing and continence management. Staff told us that the senior member of staff on each unit monitored these records. However, there was no record of this having taken place. This meant that it would be difficult for staff to ensure that people were getting the care they needed.

Is the service effective?

Staff received appropriate training and support for their role, including attendance at one to one and group meetings. Information supplied by the manager showed that staff had received training in relevant topics, including moving and handling, dementia awareness and end of life care. We noted that 33 of the 65 care staff had achieved a national vocational qualification (NVQ) in care.

Is the service caring?

Most people that we saw during our inspection were clean and well groomed. However, one person with long, dirty fingernails. The person indicated to us that they would like their nails cut. Records showed that the person hadn't had a shower or nail care in line with their care plan. This meant their needs had not been met.

People told us they were satisfied with the care they received. One person who had recently moved the home told us, 'This is quite good, I've not found any fault yet." Another person told us, 'The staff are lovely. You never hear raised voices to residents.'

Both relatives told us that they were happy with the care provided and that staff kept them informed of any changes in their family member's condition. One relative told us that they had the experience of a number of care homes. They said that, 'Some were more glamorous than this, but the care here has been better than anywhere else'.The staff do understand my [family member's] needs. Everyone's been brilliant.' The other relative also made positive comments but told us that when a new regime had been implemented this had only happened for a while and then stopped.

We spoke with a health care professional who visited people at the home regularly. They said they felt the home provided good care. They said, 'I really think this place is very good. I have no concerns and am happy with care and treatment provided.'

On the whole we saw that staff communicated well with people and provided sensitive assistance where people required support. They spoke in a calm and respectful way, giving time for people to respond to them. However, we heard one member of staff speak to people in a terse and patronising manner. We also heard this member of staff try to instigate a conversation with another member of staff, ignoring the person the other staff member was assisting. On two occasions we heard members of staff calling across communal areas, where other people were present, requesting information about people's care.

Is the service responsive?

Where people had capacity to make decisions for themselves, we found that staff consulted them before providing their care. However, none of the people we spoke with could remember seeing their care plan. Records did not show that people had been involved in writing their care plans.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. We found that staff had received training in the MCA and the DoLS, and there were proper policies in place to ensure that people who could not make decisions for themselves were protected. However, these were not being consistently followed across the whole of the home. This meant that people may be at risk of decisions being made that were not in their best interest.

People told us that staff responded when they called for assistance and we saw most people had call bells within easy reach. However, we noted that one person was unable to reach their call bell. This meant the person may not have been able to summon assistance if they had needed it.

Is the service well-led?

Management of the home had not been stable in the last year. The last manager who was registered with the Care Quality Commission (CQC) left the service in May 2013. A manager had been appointed and taken up post, but they left earlier this year. The manager at the time of our inspection had taken up the post in late May 2013. Staff told us the current manager was approachable and that they felt able to talk with her.

The provider had a comprehensive quality assurance system in place to audit and monitor the quality of the service provided. The provider carried out regular surveys to obtain the views of people receiving care and other stakeholders, including relatives and visiting professionals. The responses received in May 2014 had been mainly positive and we saw that the current manager had reviewed these and taken action to address any shortfalls where appropriate.

Regular meetings were held for the people living in the home and their relatives and the various groups of staff. This provided an opportunity for people, their relatives and staff to voice their opinions and for the manager to share information.

There was a comprehensive programme of audits that the managers completed to monitor the service provided. We could see that where areas for improvement were identified, these had been followed up to ensure they had been actioned. However, we found one person's care plan had been audited and found to be 100% compliant with the provider's standard. However, we found that some important information was missing from the person's care plan. The manager rectified the shortfall immediately. The manager told us that following our inspection a Quality Officer was visiting the home and completing further audits of people's care plans. In addition they told us that they had taken steps to improve the record keeping in the home. This included the re-introduction of paper based charts for staff to record people's food and fluid intake.

If you wish to see the evidence supporting our summary please read the full report.

17 February 2014

During a themed inspection looking at Dementia Services

St Georges Court Care Centre had three separate units in the home. One unit provided care and support specifically for people who were living with dementia. The other two units provided nursing care and support to mainly older people, some of whom were also living with dementia.

People who lived there told us they were happy and one person said, 'I feel safe'.

Relatives we spoke with or who left us comments cards complimented the care and support staff gave people. One person said, "I haven't seen my (relative) smile so much in all the years I have known them. The staff are so kind'.

However, one person was concerned about the number of staff and told us they had seen people who had to wait over an hour to get help to go to the toilet.

The care delivered to people did not always meet the needs of people who were living with dementia. We also observed that when staff communicated with people, the level of their interactions varied. This was because some staff spoke with people in a very limited way while others were able to engage people with the activity or task and initiate conversations.

Staff made an effort to get to know people they cared for and treated them with sensitivity and understanding. However, this level of knowledge was not consistent on all units of the home and did not demonstrate a clear understanding of best practice guidelines in dementia care.

Evidence that we checked demonstrated that the provider worked well with other health and social care professionals to ensure people received ongoing support.

There were systems in place to monitor the quality of care that people received and make improvements as a result of learning from feedback.

24 October 2013

During an inspection looking at part of the service

During our inspection, on 24 October 2013, we found that improvements had been made to ensure that people were protected from the risk of infection because appropriate audits had been put in place and action had been taken where issues had arisen. We found that the home was clean and hygienic throughout.

Staffing levels had been increased to ensure people's care and support needs were being met in a timely way.

18 April 2013

During a routine inspection

We observed staff working with people and looked at the records and found that people were receiving the care and treatment that they needed. One person who lived in the home told us "Staff are nice and friendly". We spoke to one relative who said that he found the staff helpful and that they did the best they could do. He said 'he did not have any cause to complain'.

We found that although there were systems in place to prevent people being exposed to the risk of infection improvements were needed to ensure that appropriate standards of cleanliness were maintained.

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Since the previous inspection the manager had recruited staff to ensure that that any staff absence could be covered. However we found that staffing levels on the afternoon shift on the ground floor sometimes meant that people had to wait up to half an hour for assistance with personal care.

There were systems in place to ensure that staff received the training and support they needed so that they could safely provide care and treatment to people using the service.

The home had a variety of ways that they monitored the quality of the service being provided. People who lived in the home and their relatives were encouraged to give their views about the home and had been involved in decisions about their care.

26 October 2012

During a routine inspection

During our inspection of St Georges Court on 10 October 2012 and 26 October 2012 we used a number of different methods to help us understand the experience of people using the service. This was because some of the people using the service had complex needs which meant that they were not able to tell us about their experiences.

People we spoke with told us they were happy at this home. They said staff treated them with respect and their privacy and dignity were maintained. One person said, 'I'm looked after very well. I'm very well treated and respected'. A family member said, 'I'm so pleased with the care my [relative] is getting'.

People told us they were able to make choices in most areas of their daily lives, including about the care they received, the food they ate and what they did during the day. However, people who needed staff to support them did tell us they sometimes had to wait for assistance when staff were busy.

A member of staff said, 'The management are really good, they provide everything for the residents who are looked after really well'. Another member of staff told us, 'I'm very happy here. It's really lovely. It's about the people; they [the company] genuinely care'.

People said they felt safe, they received the care they needed in the way they preferred, and they knew how to make a complaint.

People liked the staff. However there were not always enough staff to meet all their needs in a timely way.