We carried out this unannounced inspection on 25 September 2018.

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 plac

We carried out this unannounced inspection on 10 April 2018.

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 staf

This inspection took place on 2 and 3 August and 6 September 2017 and was unannounced. At the previous inspection in October 2014 we rated this service “requires improvement” but did not identify any breaches of legal requirements.

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 n

We spoke to seven people who used services, six relatives and friends, the assistant matron, the sister of the home, three members of care staff, a handyman, a chef and two members of the administrative staff. People's care and treatment was delivered in a way that was intended to ensure their welfare and safety. People who used the service told us 'the staff are fabulous' and 'they're all kind and helpful'. Relatives told us 'people are wonderfully looked after' and 'we couldn't ask for better'.

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.

Everyone we spoke said that they were treated with dignity and respect. People said that staff were approachable, kind and provided care in the way that they preferred. People said that they were able to make choices on how to spend their day, and went out independently if they are able to do so.

People we spoke with said that they felt comfortable at St Georges Nursing Home and said that they were pleased with the care and treatment they received.

People told us they felt safe and cared for by staff who were trained to meet their needs. They said they knew how to raise concerns and would do so if they needed to.

During our visit people who use the service said staff treated them with respect and dignity. They were enabled and encouraged to make their own decisions and choices, including care, treatment and joining in with activities provided if they wished. They said St George’s was a very good place to live in where they felt safe and protected by a competent and professional staff and management team. They also thought the food was good with suitable choices available of the type they enjoyed.

They told us staff are very friendly, supportive and there are adequate numbers to meet their needs. They also received their medication on time.

They were aware of how to complain, who to and were confident they would be listened to and complaints investigated.

We carried out an inspection on 27 and 28 October 2014. This was an unannounced inspection.

St George’s Nursing Home is a 44 bedded nursing home providing personal care and nursing care to adults, some of whom have dementia and/or other mental and/or physical health needs. The home also provides respite care and support and treatment to people nearing the end of their lives.

At our last inspection on 2 January 2014 we asked the provider to take action to ensure staff received appropriate training and supervision to enable them to deliver care and treatment to people in a safe and appropriate manner. We received an action plan on 2 June 2014 from the provider stating how they would meet the required standards and by when.

The provider was meeting the required standards when we carried out our visit on 27 and 28 October 2014. Staff had recently completed training sessions in dementia awareness and end of life care. Staff told us they had found the sessions useful and had been able to put learning into practice when caring for people living in the home. Staff commented that the provider always encouraged them to complete further relevant training and supported those who were studying to become qualified and registered nurses.

We were told by the provider that due to recent staff absences, supervision had been completed for some but not all staff. Staff told us they felt able to raise any concerns they may have at any time by speaking to the manager or senior nursing staff. One member of staff said, “I’m always able to speak to the manager, she’s a good listener and will always help out.”

The provider was registered with the Care Quality Commission. Registered providers, whether an individual, a partnership or an organisation have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider assumed responsibility for the management and day to day running of the service. There was no requirement for a separate registered manager.

Many of the senior nursing staff had been working at the home for over 10 years. One member of staff told us, “This is a friendly home and we are all treated very well.” People and their relatives/friends spoke very highly of all the staff at all levels. The care staff we spoke with were polite and friendly and demonstrated a positive and professional attitude whilst carrying out their duties. Staff had a good understanding of people’s needs, interests and preferences and were able to tell us something about the social networks and background history of each person living at the home.

Staffing levels were determined according to the needs and dependency levels of people using the service. Staff had relevant qualifications in nursing, health and social care and/or previous experience of working in care settings. New staff were required to complete an induction programme and shadow more experienced members of the staff team prior to working on their own with people using the service.

People’s needs were assessed and care plans were developed to identify what type of care and support people required. People were involved in making decisions about their care wherever possible. If people were unable to contribute to the care planning process, staff worked with people’s relatives and representatives to assess the care they needed. However, not all care plans and risk assessments were maintained and/or reviewed in line with the provider’s policies.

People told us they were happy with the care and support they received. One person said, “I’m so pleased to be here, they [the staff] are so kind.” Another person told us, “It’s lovely here, we are all very well looked after.”

Staff were knowledgeable about how to recognise the signs of potential abuse and aware of the appropriate reporting procedures. The provider was meeting the requirements of the Deprivation of Liberty safeguards (DoLS). Nursing staff had been trained to understand when a DoLS application should be made and knew how to submit one and to whom.