Archived: St Elizabeth's Care Home with Nursing

St Elizabeth’s Care Home with Nursing provides both nursing and personal care to up to 110 people in 11 bungalows and three single occupancy flats, within a campus style community. The service specialises in offering care and support to people with epilepsy, associated neurological disorders, a learning disability and other complex medical conditions. At the time of the inspection there were 86 people living at the home.

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

People were at risk of not having their needs met in a timely manner. The provider acknowledged that there were not enough staff available to meet people’s needs. They told us they were having to prioritise personal care and safety over supporting people to go out or learn new skills.

The majority of risks in relation to people’s health, safety and well-being had been identified and assessed. However, these assessments did not always enable people to be in control of taking calculated risks. Furthermore, records indicated that risk assessments were not always followed by staff, for example, in relation to repositioning, choking or dehydration risks.

We identified a number of issues relating to the environment and repairs required. This included cracked tiles and flooring in bathrooms, exposed hot water pipes and a light fitting hanging from the ceiling in one of the bungalows. Staff told us they had reported these concerns but there was a long waiting list for repairs. Immediate risks were reported to the management team on the day of inspection and interim measures taken to ensure people’s safety.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Not all staff we spoke with were aware of the principles of the Mental Capacity Act and these principles were not consistently embedded in their practice. This meant there were restrictive practices in place, such as locked doors. There was no evidence that the provider had considered if this was the least restrictive action to take.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. Staff did not always consider people’s individual needs nor promote choice and control. The language used in care plans and by staff did not always promote a respectful, personalised approach and this had not been identified by the management team. For example, care plans referred to people “absconding” from their own homes. A staff member also told us, “This is where people come to die”, in reference to the bungalow they were working in.

People’s independence was not promoted. For example, in meeting minutes for one bungalow, it stated, “Cooking in the bungalow by residents still needs to be organised as it is time consuming and as staff are busy, it would be as time allows and needs to be planned in advance.” This suggested that the development of people’s independent living skills was not embedded in the day to day operations of the service

We found that people were not always treated with dignity and respect. For example, staff did not knock on doors when entering people’s rooms and we were shown into rooms where people were in bed or being supported with personal care. Care and support plans did not always focus on positive outcomes to improve people’s quality of life. There was limited evidence that staff supported people to identify aspirations for the future. Where wishes were identified they were not always personalised or meaningful to the individual.

Due to living within a campus style community, in a rural location, people were dependent on staff to leave the site safely. However, people did not have control over when they could leave, and staff confirmed it would be difficult for them to facilitate any spontaneous trips out, with this situation exacerbated by staffing difficulties and the COVID-19 pandemic. Daily records indicated that people had a limited choice of things to take part in during the day, and infrequent opportunities to leave the St Elizabeth campus.

The management team had not identified issues we found regarding the culture of the service. They had produced a service improvement plan; however, this did not include actions around how they intended to embed the principles of Right support, right care, right culture at the location.

The provider did not clearly distinguish between the responsibilities of the staff employed by the care home and those employed by the on-site health agency. St Elizabeth’s Care Home with Nursing is registered to provide both personal and nursing care. However, all nursing care was provided by the on-site health agency. This arrangement meant that records were sometimes disjointed or missing. For example, health records held at the bungalows were not always up to date. We were told this information was managed by the on-site health agency. This meant important information was not accessible to the staff supporting people on a daily basis.

The provider’s systems for understanding what was happening within the home were not effective, they had failed to operate effective monitoring of the quality of care. We identified gaps in care plans, risk assessments and daily records. These had not been identified by the provider. Continuous learning was not promoted within the service, with lessons learned following incidents and safeguarding concerns not shared with all staff.

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 (published January 2018). Since this rating was awarded the provider has altered its legal entity. We have used the previous rating to inform our planning and decisions about the rating at this inspection.

Why we inspected

This was a planned inspection based on the previous rating.

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. This included checking the provider was meeting COVID-19 vaccination requirements.’

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to management of risk, staffing, the environment, restrictive practices, developing care that is personalised and the provider’s oversight of quality at this inspection.

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.

About the service

St Elizabeth’s Care Home with Nursing provides both nursing and personal care to up to 110 people in 11 bungalows and three single occupancy flats, within a campus style community. The service specialises in offering care and support to people with epilepsy, associated neurological disorders, a learning disability and other complex medical conditions. At the time of the inspection there were 85 people living at the home.

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

Right support

People were not always supported to pursue their interests, Although there had been more opportunity since the last inspection, People were still not able to have regular involvement in the local community and we saw a large number of people continued to have days where they did not have the opportunity to do different things. Due to staffing restrictions there were times where people could not have a fulfilling and meaningful everyday life.

Staff did not adhere to safe practices when wearing personal protective equipment (PPE) and manual handling. This meant that people were at risk of harm.

The provider failed to ensure people were supported with their medicines in a way that promoted their independence and achieve the best possible health outcomes.

The provider failed to support people to have maximum possible choice, control and independence. We found there were decisions that restricted people without this being in their best interest.

People did not live in an environment that was safe, clean or well-maintained. The environment required extensive works to ensure it was fit for people’s needs, however the provider had planned to complete works and this had started during the inspection.

Right Care

People were not always supported by a service that had systems in place to report and respond to accidents and incidents. Staff did not always understand how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse, however we observed staff providing care that was not safe.

People did not always receive kind and compassionate care. We observed staff supporting people in a way that did not respect their privacy or dignity. Staff did not always understand how to respond to people’s individual needs.

The service failed to ensure there were enough appropriately skilled staff to meet people’s needs and keep them safe.

There was fluctuation of staffing within the service. People and staff shared there were times where they were short staffed, and this affected people’s care.

People’s care and support plans failed to always reflect their range of needs. There was limited detail about promoting their wellbeing and enjoyment of life. People did not always receive care that supported their needs and aspirations. Staff did not focus on people’s quality of life or followed best practice.

Right culture

People did not always have risk assessments in place, to identify risks people faced and how staff should manage these, information found was not always current or accurate, Staff were not always knowledgeable about the content of these risk assessments. When risks to people were identified actions to mitigate the risks were not always resolved in a timely manner which put people at risk of harm.

People were supported by staff who did not always understand best practice in relation to supporting people with a learning disability, there were areas of improvement needed in relation to training and ensuring staff had the right skills, however the provider had started to address this.

People’s quality of support was not enhanced by the providers quality assurance system the provider had in place. Actions were not always documented, and it was unclear if actions were completed. This had an impact on people’s care.

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 inadequate (published 02 March 2022). At this inspection we found the provider remained in breach of regulations.

This service has been in Special Measures since 02 March 2022 During this inspection the provider did not demonstrate that adequate improvements had been made. Therefore, the service remains rated as inadequate overall and remains in Special Measures.

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support right care right culture.

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.

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 safe, effective and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. 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 Elizabeth’s care home with nursing on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to keeping people safe, not having enough staff which impacted peoples day to day life, systems surrounding peoples medicines were not managed well, people were supported by staff who did not promote kind and compassionate care which resulted in safeguarding issues, the environment was not fit for purpose and required work to ensure it was a nice environment to live in, people were not always supported with the least restrictive option and the management oversight did not always identify where improvements were needed and did not action this in a timely manner 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.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

We found the following examples of good practice.

The provider created `bubbles` of two or three bungalows. This meant that although staff were allocated to work in one bungalow in case of staff shortages staff could support people in their bubble.

Staff understood the importance of following best practice and national guidance for infection prevention and control (IPC) and personal protective equipment (PPE). IPC leads in each bungalow monitored staff practices carried out audits and made improvements where needed promptly.

Staff and people were regularly tested and processes were in place to ensure if anyone visited the service they could do so after they were tested. Routine social visits could not take place but arrangements were made for each individual person if it was needed to see their family if this was in their best interest.

Risks to people and staff in relation to their health, safety and wellbeing had been thoroughly assessed. There was support for staff in place which included provision of training and regular supervisions. The provider made arrangements for staff to meet with them on an individual basis to discuss if they had any concerns about testing or vaccination.

A robust package of policies, procedures and guidance had been developed by the provider to support staff in making sure their practices were safe and protected people from the risk of infections. These included a robust and enhanced cleaning program.