About the service: St Bernadettes is a care home, which provided personal and nursing care to 20 people aged 55 and over at the time of the inspection. The home is registered to accommodate a maximum of 27 people.

People’s experience of using this service: Since our last inspection the provider had failed to maintain high quality standards of practice within the service. The provider demonstrated their motivation to improve by working with us during and after the inspection.

Families told us that levels of communication between themselves, staff and management were poor. Despite them repeatedly asking for updates of their relative’s wellbeing three families said their requests for information had been ignored. They also had little input to their relative’s care and were not involved in care reviews.

Medicines were not always managed safely within the service and the registered manager had raised safeguarding alerts about these with the local authority.

People were looked after by staff who had not always received sufficient induction, training and support to ensure they could fulfil their role safely. Adequate checks of agency staff skills and identities had not been carried out. This put people at risk of avoidable harm.

Care plans and risk assessments were not reviewed on a regular basis or when people’s care needs had altered. The quality of the record keeping varied and some care records we looked at did not have the full information in them to manage people’s care safely.

People did not always have an opportunity to take part in stimulating and enjoyable activities. There was a lack of social events within the service.

People were able to talk to health care professionals about their care and treatment. People could see a GP when they needed to and they received care and treatment when necessary from external health care professionals such as the district nursing team and speech and language therapists (SALT).

More information is in detailed findings below.

Rating at last inspection: Good (report published on 4 October 2017). The rating has deteriorated to requires improvement at this inspection.

Why we inspected: We were notified about a serious incident in which a person using the service died. We also received information about medicine errors in the service. We looked at risks associated with these concerns.

Enforcement: We identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around person-centred care, safe care and treatment, good governance, staffing and fit and proper persons employed. Details of action we have asked the provider to take can be found at the end of this report.

Follow up: We will work with the provider following this report being published to understand and monitor how they will make changes to ensure the service improves their rating to at least Good.

This inspection took place on 31 July 2017 and was unannounced.

At our last inspection in August 2016 we identified two breaches of regulation. We had asked the provider to take action to improve infection prevention and control practices and carry out robust audits of the service and working practices.

During this inspection we found that the provider had taken action to improve practices within the service. We found these improvements were sufficient to meet the requirements of Regulation 15: Premises and equipment and Regulation 17: Good governance. This meant the provider had met the breaches of regulation identified at the previous inspection.

St Bernadettes is a care home providing nursing and residential care and support for up to a maximum of 27 people. At the time of our inspection there were 24 people who used the service.

The provider is required to have a registered manager in post and at the point of reporting the manager’s application to register had been approved by the Care Quality Commission (CQC). A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Medicine management practices were being reviewed by the manager and action was taken during our inspection to ensure medicines were given safely and as prescribed by people’s GPs. We have made a recommendation in the report about this.

Infection prevention and control practices within the service ensured the environment was clean and hygienic, but the manager was aware that further work was needed to ensure best practice was always followed. We have made a recommendation in the report about this.

People told us they felt safe and were well cared for. There were sufficient staff employed to assist people in a timely way and recruitment of staff was carried out safely.

People that used the service were supported by qualified and competent staff that were regularly supervised regarding their personal performance. Appraisals for staff were planned for the forthcoming months. Communication was effective, people’s mental capacity was appropriately assessed and their rights were protected.

People had their health and social care needs assessed and plans of care were developed to guide staff in how to support people. The plans of care were individualised to include preferences, likes and dislikes. People who used the service received additional care and treatment from health professionals based in the community. People had risk assessments in their care files to help minimise risks whilst still supporting people to make choices and decisions.

Staff were knowledgeable about people’s individual care needs and care plans were person centred and detailed. There was a range of social activities available and people’s spiritual needs were met.

People told us that the service was well managed and organised. The manager assessed and monitored the quality of care provided to people. People and staff were asked for their views and their suggestions were used to continuously improve the service.

This inspection took place on 15 August and was unannounced. St Bernadettes Nursing Home is part of the Complete Care Homes group. It is set over three floors, with two lifts available to access different areas of the upper floors. It provides accommodation and nursing care for up to 27 older people, some of whom may be living with dementia. At the time of our visit there were 22 people living at the service.

At the last inspection in May 2014 we asked the provider to take action to make improvements (for example; the staffing levels and maintenance of equipment and records), and this action had been completed when we undertook a follow up inspection in September 2014. You can read the report from our last inspection, by selecting the 'all reports' link for St Bernadettes Nursing Home on our website at www.cqc.org.

There was a registered manager at this service. 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.

Two of the bathrooms at the service were in a poor state of repair, with cracked tiles and flooring that was not sealed. Therefore making it difficult to clean thoroughly. The ground floor shower room had a malodorous drain. These factors meant the premises and equipment was not clean or properly maintained.

This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the back of the full version of this report.

The service ensured that staff were recruited safely and they been through an induction process, whereby they shadowed more experienced workers before working independently. Staff had received training that gave them the skills to protect people from harm and they knew how to report any concerns they had regarding safeguarding.

Regular staff meetings were held and staff received appropriate supervision. They told us they could raise any concerns they had and discuss their development with their manager in an open manner.

Relatives and people spoke highly of the staff and we found that they were knowledgeable about the people they cared for and had received appropriate training to support them effectively. Staff worked within the principles of the Mental Capacity Act 2005 and we saw that they demonstrated a caring approach to people. Staff respected peoples’ confidentiality and privacy and asked for consent before they gave care and support.

Healthcare professionals made positive comments about the service and told us that staff listened to and followed their advice and guidance. People were offered clear explanations, by staff, when they required information and were encouraged to make their own decisions and to be as independent as they wanted to be.

People were supported to eat and drink enough and had access to healthcare services when necessary. Care plans showed that staff followed the guidance of healthcare professionals.

Activities were in place that people enjoyed. The service was developing further activities based on feedback from people and discussion around new activities that could be implemented.

Care plans contained information about people’s lives, their interests and preferences, which gave staff information about people as individuals.

Complaints were dealt with appropriately and recorded. Actions were taken by the registered manager to respond to the person making the complaint. The responses addressed the issues and resolved them in a positive manner. Where necessary the service made improvements to make sure issues were addressed and lessons learned.

Audits were carried out regularly to monitor and review any areas for improvement. The results of audits were not consistently acte

A single inspector carried out this inspection. The focus of the inspection was to answer the questions: is the service safe and effective.

We wanted to check that the provider had taken action to improve three areas that we found none compliant at our last inspection of this service.

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

Is the service safe?

During our inspection we found that the provider had taken steps to ensure the service was conducted in a way that ensured people were safe. Maintenance records were accurate and up to date and equipment was maintained according to the manufactures guidance. The provider was maintaining staffing levels so that people received the support they required and they had taken steps to ensure they remained fully staffed thus ensuring people’s safety.

During our visit we observed staff treating people with dignity and respect. They gave people the support they required in a measured and timely way. People told us “The staff are great they always give me time” and “The staff are very good in fact one of them is taking me out this afternoon”

We saw that people’s records were personalised and up to date. This ensured that staff were able to support people appropriately.

Is the service effective?

We saw records to indicate that regular audits of the systems used in the home were being carried out. This allowed the management of the home to identify areas of shortfall and what actions they needed to take to ensure the service was run effectively. We saw that staff responded to people’s needs in a timely manner.

Audits undertaken relating to the maintenance of the home were up to date and accurate. This helped to advise the management team and meant that people lived in a safe and well maintained environment.

Since our last inspection there has been a change in manager. Staff told us the new manager was approachable and fair. They encouraged staff to undertake training. Staff also told us that the staffing levels needed to ensure people received the support they required were now maintained and people were not pressured to cover shifts. They told us the atmosphere in the home was more relaxed and positive with the new manager.

A single inspector carried out this inspection. During the inspection, the inspector focussed on answering five key questions; is the service safe, effective, caring, responsive and well-led?

As part of this inspection we looked at records for four people who used the service. We spoke with the interim manager and a manager from a sister home who came to assist during the inspection. We also spoke with people who lived in the home and care staff. We also reviewed records relating to the management of the home.

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

Is the service safe?

We had received information prior to carrying out the inspection regarding various elements of the service. This included information regarding the staffing levels and the impact that this was having on the delivery of safe support to people.

During our visit the interim manager and staff confirmed that there had been some staffing issues and that this had caused there to be staff shortages on numerous occasions. When we looked at rotas we confirmed this to be the case. When we spoke with people who used the service comments included “There is sometimes a shortage of staff and I have to wait a little longer for support which is frustrating” and “I don’t feel that staff issues are having a major impact but they have to work very hard to make us comfortable when there are so few of them”. When we spoke with staff they confirmed that there were staffing issues and that these impacted on the amount they could get done during a shift. This meant that it would not have been possible to carry out care and support to a high level due to the strain on staff members.

As well as receiving information of concern regarding the safety and suitability of the premises prior to the inspection, we had found similar concerns at previous visits. Although we found that improvements had been made with regard to some areas of the home, there were other areas where further work was required to ensure the premises were safe and suitable for people. This work was on-going at the time of our inspection and other work was yet to commence.

Is the service effective?

People had an individual care plan. We saw that the care plans contained some useful information and in some cases families had been involved in the development of these. However some had been written some time ago and although updates were recorded these were not always clear and sometimes gave contradicting information. There was a programme to audit care plans being carried out but this was not clearly recorded so it was not possible to ascertain how many had been completed at the time of our visit. The risk assessments that were available were sufficiently detailed to identify and minimise risks. However we found one file which indicated the person was supported in their room at all times but there was no specific risk assessment in place for moving and handling this person. This may have indicated that the service had not always appropriately assessed risks and provided guidance for staff about to how to manage and minimise risks.

When we spoke with people who used the service they were very pleased with the support they received from staff. One person told us “I am quite happy and I feel well looked after”. When we spoke with staff they told us that they felt they were doing their best to provide good and effective care but that morale was low and staffing challenges made this difficult. None of the staff we spoke with felt that people were not getting the care they needed with regard to eating and drinking, personal care and medication.

Systems in place for highlighting issues were not being used to their full potential and some of these were being redesigned at the time of our visit following a change in management structure. This meant that some areas still required improvement in order to clearly demonstrate how learning from things like accidents, incidents, surveys and resident meetings, staff feedback and complaints were leading to the improvement of the service.

Is the service caring?

All the staff we spoke with were committed and enthusiastic to effect improvements and provide a sustainable, effective service. There was no manager in post at the time of our visit and these tasks were being picked up by an interim manager and the general manager from the provider group who was assisting. The home was in the process of recruiting a new manager.

Individual carers spoke confidently about the high standard of care they wanted to provide. The interim manager was also keen to ensure that the service was offering the best quality service it could.

When we spoke with people who used the service they were very complimentary about the quality of support that was provided by most staff. One person told us “The staff are very good and there just needs to be a few more of them”. The interactions we observed throughout our visit were very good. Staff spoke with people in a friendly and clear manner. When people were assisted to move or complete an activity instructions and support were straightforward and appropriate in nature. Staff knew people well and offered care that was calm, clear and friendly.

Is the service responsive?

As part of our inspection we fed back some of our concerns to the interim manager and the manager from a sister home about some of the shortfalls we had found during our visit. We also had further information sent to us regarding some of the checks that were being carried out at the service in order to action plan for improvement.

There were systems in place for monitoring some aspects of the service. These audits had not always been kept up to date prior to the change in management structure and the current interim manager and general manager were working their way through some of these at the time of our visit and there were further actions required following these audits to ensure that the service was improving.

The management arrangements meant there was ongoing work being completed and action planning was to be the next stage. This showed the service was trying to be responsive to the highlighted areas of need.

We have also asked the provider to consider the report and to tell us in writing what they are going to do to improve the service.

Is the service well-led?

Due to changes in the structure at the service there had been some upheaval in management arrangements and this had impacted on the service in a number of ways. Although there were interim arrangements in place, this had not ensured that on-going issues were tackled appropriately and new issues had arisen as a result of auditing and monitoring of the systems and processes in the home by the general manager.

The staff we spoke with and information we received prior to the inspection indicated that there were staff shortages. This was verified by looking at rotas during the inspection and speaking to the interim manager. However, the way in which this and other issues had been tackled with the staff team had meant that there was some issues around morale, duty and responsibility, capabilities and building team relationships. This required looking at to ensure that there was no further impact on the service being delivered.

During our inspection people we spoke with told us they were happy with the support they received. One person told us “Getting the help I need is important to me and they support me”. A relative told us “Everything is alright as far as I am concerned. They meet my relative’s needs very well and they seem happy living here”. We saw that care planning was detailed and regularly reviewed.

People were given a choice of meals and drinks and weight and dietary intake was monitored when required. Appropriate referrals were made to other services and organisations and the communication and level of detail in recording input was good.

There were some improvements needed to the maintenance and safety of the premises although these were minor issues that could be easily addressed and did not pose any immediate or serious risk to people using the service.

There was a good audit system in place and this was used appropriately most of the time. There were opportunities for people who used the service and staff to put forward ideas, suggestions and issues. The complaints system in use was clear and was being followed appropriately.

We visited St Bernadettes in January 2013. We found that people had their care and treatment explained to them in a way they could understand and had been given opportunities to give consent to various things including care and documentation. We spoke to people who used the service who felt that they were cared for to a high standard. One person told us "I feel happy here, it is my home".

We looked at care plans and risk assessments and found them to be detailed and individualised. People were engaged in activities and interaction with staff throughout our visit and people reported feeling listened to and respected.

We looked at safeguarding people and found there to be systems and practices in place that protected people and kept them safe. The service was following procedures appropriately. We also looked at infection control policies and procedures as well as the cleanliness and hygiene of the home which was of a high standard.

Recruitment and induction processes used in the service were effective and staffing levels were managed well and meant that people were able to get the support and care they needed in a timely and relaxed manner.

The service had detailed and robust systems for monitoring the quality of the service and there were numerous ways that feedback was collected and subsequently acted on to ensure that the support offered and the running of the service worked for the people who lived there.

People told us that they were happy with their care and with the staff team. They told us that they felt that staff were competent in their roles and met their needs. When asked, people told us that staff were kind, competent and skilled.

People told us that they were happy living in the home. They felt that their needs were being met by competent and polite staff. They said that staff gave over 100% and that they felt safe living in the home.