St George’s Nursing Home is a 'care home'. 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 purpose-built home is registered to provide accommodation for up to 60 older people who require nursing and personal care. At the time of the inspection 26 people were living at the service.

The inspection took place on 12 December 2018 and was unannounced.

There was a registered manager in post. 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. The registered manager was on leave during the inspection; however, the deputy manager, clinical lead and head of human resources and administration made themselves available to us throughout the inspection.

At the previous inspection on 5 June 2016 the service was rated as Good. At this inspection we rated the service Requires Improvement because the provider’s quality assurance processes were not robust. We found shortfalls in relation to environmental checks, infection control, care planning and statutory notifications. Although the provider told us after the inspection that they had rectified the issues, there was a risk that the provider’s auditing processes were not adequate.

People and their relatives told us they felt safe. Staff had been trained to keep people safe from avoidable harm. Care plans contained risk assessments and care plans provided clear guidance for staff on how to reduce the risks.

Incidents and accidents were reported and analysed to identify trends. There was evidence that lessons were learned when incidents happened.

Medicines were managed safely.

Staff were trained to undertake their roles. Staff had regular supervisions with a supervisor.

People were supported to have enough to eat and drink.

People using the service spoke highly of the staff and all were happy with the support they received. We observed positive interactions between staff and people. People were asked regularly for their feedback.

Care plans were not always person centred and some of the plans we looked at did not provide clear guidance for staff on how to meet people’s needs.

Complaints were logged and investigations and outcomes documented.

All the staff told us the service was well managed. People using the service and their relatives gave positive feedback about the management team.

We found one breach of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we told the provider to take at the back of the full version of the report.

This inspection was unannounced and took place on 5 and 6 May 2016. We had previously carried out an inspection in April 2015. At the inspection in 2015, we found there was a breach in regulations in relation to the duty of candour and the recording of complaints. At this inspection, we found improvements had been made in both these areas.

St George’s Nursing Home provides nursing and personal care for up to 60 older people, some of whom were unable to move independently. Some people were living with dementia and had communication difficulties because of their health needs. Other people required support because of illness or other age related conditions. End of life care is also provided. St George’s is a large purpose built two storey detached property. There were 30 people receiving care at the time of our inspection.

There was a registered manager in post. 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 and associated Regulations about how the service is run.

The registered manager had taken steps to make sure that people were safeguarded from abuse and protected from risk of harm. People told us they felt safe. People were protected from harm; risks to their safety were assessed and managed appropriately. People were involved as far as possible in their assessments and action to minimise risk was agreed with them.

The provider operated safe recruitment procedures, which included carrying out legally required checks on every applicant to make sure they were suitable to work with the people who lived at this service.

Staff told us there was a good atmosphere and staff worked as a team. They told us there were just enough of them to care for people and keep them safe.

People told us, occasionally they had had to wait when they needed help or support but this had improved recently.

Staff were provided with suitable training to enable them to carry out their roles. People told us, “Staff have been very good.” “All the nurses and carers are good” and, “They look after me well”.

Staff understood their roles and responsibilities. They told us they felt well supported and were provided with essential training, including induction to make sure they had the knowledge and understanding to provide effective care and support for people.

Nursing staff were supported to continue their professional development.

All staff received regular supervision and appraisal to make sure they were competent to deliver appropriate care and treatment.

Staff received Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) training to make sure they knew how to protect people’s rights. Staff understood the importance of obtaining consent from people before care or treatment was provided.

People told us they enjoyed the food. They said, “They (staff) go to no end of trouble to please you where food is concerned”. People were offered choices about what they wanted to eat and drink. People who needed support to eat were helped with care. Meal times were managed well to make sure that people received the support and attention they needed.

People were supported to manage their health care needs. Nursing staff carried out regular health checks on people who lived in the home and these were recorded.

People told us they were able to see a GP whenever they wanted to. Records showed that people saw other health professionals such as physiotherapists, chiropodists, dentists and opticians when they needed to.

People were treated with respect, kindness and compassion. People told us they were happy and felt cared for. They said, “The care here is excellent” “The carers are good and kind” and “Everyone is treated with respect”. All agreed that they felt listened to.

Each person had an individual care pla

We considered the evidence we had gathered under the outcomes we inspected. We spoke with three people who use the service, one visitor, four members of staff and the manager. We also looked at eight care plans and records related to the management of the service. Our inspection team was made up of one inspector. We used the evidence to answer five questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Is the service safe?

People told us that they felt safe. Safeguarding and whistleblowing procedures were robust and staff understood how to safeguard the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the provider to maintain safe care. The provider had robust policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. At the time of inspection, one person was subject to Deprivation of Liberty Safeguards. We found that the process was conducted in a manner consistent with the law.

Is the service effective?

People's health and care needs were assessed with them and they or their representatives were involved in the compilation of their care plans. People said that they had been involved in the process and that care plans reflected their current needs.

Visitors confirmed they were able to see people in private and that visiting times were flexible.

Is the service caring?

We spoke with people who live at the home. We asked them for their experience about the staff that supported them. Feedback from people was positive, for example one person said, "I love it here and the staff are great". Another told us, "It can never be like your own home but it's the next best thing".

People who live at the home and their families were asked to complete a satisfaction survey by the provider. These were used to help improve the service in the future.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The home worked well with other agencies and services to make sure people received care in a coherent way.

People knew how to make a complaint if they were unhappy. Complaints were dealt with in a timely and satisfactory manner.

People engaged in a range of activities both in the home and in the wider community.

Is the service well-led?

The service operated a quality assurance system which identified and addressed shortcomings. As a result, a good quality of the service was maintained.

The staff we spoke with were clear about their roles and responsibilities. They had a good understanding of the needs of the people they were caring for and were properly trained and supported to carry out their duties.

We were satisfied that the areas for improvement and non compliance had been addressed.

We found that new arrangements were in place in relation to the locking of people's rooms and where people were able to have meals. This enabled people to exercise choice and respected their right to access their room independently and at a time they wished. People were able to have their meals where they chose which included the lounges. This provided an opportunity to have meals away from the majority of people, if this suited them, respecting their need for privacy and choice.

The provider had addressed the need for specialist training to provide staff with the necessary skills and knowledge to do their job. We found that staff had received one to one supervision. Staff were very positive about the training that had been provided since our previous visit and the opportunities for further training.

The provider had addressed the areas of non compliance in relation to a lack of auditing and quality monitoring. We saw that improvements had been made as a result of infection control and management of medicine audits.

This inspection was unannounced and took place over four days on 15 April, 20 April, 22 April and 23 April 2015.

St George’s Nursing Home is registered to provide personal and nursing care for up to 60 people. The home specialises in the care of older people with dementia. At the time of this inspection there were 31 people living in the home.

The manager had been in post since 23 February 2015; however they were not registered with the Care Quality Commission (CQC) They told us they were preparing the documentation to apply to be registered. 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.

This inspection was scheduled following concerns received regarding staff shortages, end of life care, infection control and the management of risk specific to falls.

Throughout the inspection there was a relaxed and cheerful atmosphere; people living in the home, relatives and staff were happy and at ease when they spoke with us.

The manager responded to concerns and complaints in line with the provider’s policy and procedure. We looked at one complaint in detail. The complaint was received by the provider at the beginning of April and at the time of our inspection had not been concluded. By the end of our inspection the manager had responded to the complaint but the response was defensive and did not address all the issues raised. We discussed the outcome of their investigation and they agreed there had been a breakdown in communication but this was not identified in the response and no apology had been made.

Medicines were not always handled safely. Nursing staff were assisted by care workers to administer medicines. They had not checked the practice of the care workers to ensure it was safe for them to assist them. The medicines charts for some as required medicines such as pain relief did not include information for ensuring they were given in a consistent way. This was addressed during the pharmacist’s inspection and guidance was in place for staff to follow. Medicines prescribed for end of life did not include what checks the nurse should carry out before administering. This had been addressed by the end of the inspection and very clear guidance and protocols were in place.

There were systems in place to monitor the care provided and people’s experiences. However they had failed to identify specific issues until they were bought to the manager’s attention either through a complaint or our discussions during the inspection. Some shortfalls had been identified and where this happened action plans were put in place to address the issues found.

A regular survey was carried out asking people and their relatives about the service provided by the home. Suggestions for change were listened to and actions taken to improve the service provided. All incidents and accidents were monitored, trends identified and learning shared with staff to put into practice.

During the inspection we saw there was adequate staff on duty to meet the needs of people during the day. However people who could comment, relatives and staff all told us there was not enough staff at night. We saw for 31 people, five of whom were residential not nursing, 11 people required two staff to support them; there was one qualified nurse and two care workers. The manager confirmed a twilight shift had been introduced about a year ago. This meant an extra care worker supported the night staff until 11.30 at night. However this did not provide adequate support during the early hours of the morning when some people liked to get up early. The manager agreed to look at ways of also providing extra support for people early morning.

The manager had looked at innovative ways of reducing staff shortages at the weekend. They rostered on more staff than was necessary. This meant if a staff member rang in sick people did not experience poor care due to lack of staff.

The home was in the process of introducing new electronic care plans. We saw one care plan contained conflicting information about the person’s wishes. Records showed people were involved in their care plans and consented to the care they received as far as possible. Family members were involved when necessary. We saw the lack of communication between qualified staff had resulted in one family’s wishes not being recorded. This meant they were not contacted when their relative’s health declined. We recommended the service explored guidance on ways to ensure all staff were kept aware of relatives wishes.

During the inspection we observed and monitored infection control. We found the home was clean, tidy and free from bad odours. We did not observe any dirty laundry or equipment left in the wrong place. However we did observe staff did not wear aprons when serving lunch. We bought this to the manager’s attention who said they would talk with staff about the importance of wearing aprons.

We asked the manager how they managed the risks to people who had been identified as at high risk of falls. They confirmed they carried out an audit of falls and incidents which helped identify trends such as time of day or the part of the home. They would assess the need for any equipment that would help prevent injury occurring from falls. People had risk assessments in place and where equipment had been identified this was in place. This included the use of crash mats, and pressure mats to inform staff when a person was moving and one to one support for one person with very high risk of falls due to their illness. The home did not restrain people from moving about which meant falls would happen. However they did attempt to minimise the risk of injury, although injuries did sometimes occur.

Staff had received training in identifying and reporting abuse. Staff were able to explain to us the signs of abuse and how they would report any concerns they had. They stated they were confident any concerns brought to the manager would be dealt with appropriately. There was a robust recruitment procedure in place which minimised the risks of abuse to people. People who could comment told us they felt safe in the home and they all knew who to talk to if they wanted to raise a concern or complaint.

People saw healthcare professionals such as the GP, district nurse, chiropodist and dentist. Staff supported people to attend appointments with specialist healthcare professionals in hospitals and clinics. Staff made sure when there were changes to people’s physical well- being, such as changes in weight or mobility, effective measures were put in place to address any issues.

Everybody spoken with told us they enjoyed the food, they all said the food was good. People were offered choices and the food was nutritious and well presented. People who needed assistance with eating were supported in a dignified and unhurried manner. Some people chose to eat in their room.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

This inspection was unannounced and took place over four days on 15 April, 20 April, 22 April and 23 April 2015.

St George’s Nursing Home is registered to provide personal and nursing care for up to 60 people. The home specialises in the care of older people with dementia. At the time of this inspection there were 31 people living in the home.

The manager had been in post since 23 February 2015; however they were not registered with the Care Quality Commission (CQC) They told us they were preparing the documentation to apply to be registered. 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.

This inspection was scheduled following concerns received regarding staff shortages, end of life care, infection control and the management of risk specific to falls.

Throughout the inspection there was a relaxed and cheerful atmosphere; people living in the home, relatives and staff were happy and at ease when they spoke with us.

The manager responded to concerns and complaints in line with the provider’s policy and procedure. We looked at one complaint in detail. The complaint was received by the provider at the beginning of April and at the time of our inspection had not been concluded. By the end of our inspection the manager had responded to the complaint but the response was defensive and did not address all the issues raised. We discussed the outcome of their investigation and they agreed there had been a breakdown in communication but this was not identified in the response and no apology had been made.

Medicines were not always handled safely. Nursing staff were assisted by care workers to administer medicines. They had not checked the practice of the care workers to ensure it was safe for them to assist them. The medicines charts for some as required medicines such as pain relief did not include information for ensuring they were given in a consistent way. This was addressed during the pharmacist’s inspection and guidance was in place for staff to follow. Medicines prescribed for end of life did not include what checks the nurse should carry out before administering. This had been addressed by the end of the inspection and very clear guidance and protocols were in place.

There were systems in place to monitor the care provided and people’s experiences. However they had failed to identify specific issues until they were bought to the manager’s attention either through a complaint or our discussions during the inspection. Some shortfalls had been identified and where this happened action plans were put in place to address the issues found.

A regular survey was carried out asking people and their relatives about the service provided by the home. Suggestions for change were listened to and actions taken to improve the service provided. All incidents and accidents were monitored, trends identified and learning shared with staff to put into practice.

During the inspection we saw there was adequate staff on duty to meet the needs of people during the day. However people who could comment, relatives and staff all told us there was not enough staff at night. We saw for 31 people, five of whom were residential not nursing, 11 people required two staff to support them; there was one qualified nurse and two care workers. The manager confirmed a twilight shift had been introduced about a year ago. This meant an extra care worker supported the night staff until 11.30 at night. However this did not provide adequate support during the early hours of the morning when some people liked to get up early. The manager agreed to look at ways of also providing extra support for people early morning.

The manager had looked at innovative ways of reducing staff shortages at the weekend. They rostered on more staff than was necessary. This meant if a staff member rang in sick people did not experience poor care due to lack of staff.

The home was in the process of introducing new electronic care plans. We saw one care plan contained conflicting information about the person’s wishes. Records showed people were involved in their care plans and consented to the care they received as far as possible. Family members were involved when necessary. We saw the lack of communication between qualified staff had resulted in one family’s wishes not being recorded. This meant they were not contacted when their relative’s health declined. We recommended the service explored guidance on ways to ensure all staff were kept aware of relatives wishes.

During the inspection we observed and monitored infection control. We found the home was clean, tidy and free from bad odours. We did not observe any dirty laundry or equipment left in the wrong place. However we did observe staff did not wear aprons when serving lunch. We bought this to the manager’s attention who said they would talk with staff about the importance of wearing aprons.

We asked the manager how they managed the risks to people who had been identified as at high risk of falls. They confirmed they carried out an audit of falls and incidents which helped identify trends such as time of day or the part of the home. They would assess the need for any equipment that would help prevent injury occurring from falls. People had risk assessments in place and where equipment had been identified this was in place. This included the use of crash mats, and pressure mats to inform staff when a person was moving and one to one support for one person with very high risk of falls due to their illness. The home did not restrain people from moving about which meant falls would happen. However they did attempt to minimise the risk of injury, although injuries did sometimes occur.

Staff had received training in identifying and reporting abuse. Staff were able to explain to us the signs of abuse and how they would report any concerns they had. They stated they were confident any concerns brought to the manager would be dealt with appropriately. There was a robust recruitment procedure in place which minimised the risks of abuse to people. People who could comment told us they felt safe in the home and they all knew who to talk to if they wanted to raise a concern or complaint.

People saw healthcare professionals such as the GP, district nurse, chiropodist and dentist. Staff supported people to attend appointments with specialist healthcare professionals in hospitals and clinics. Staff made sure when there were changes to people’s physical well- being, such as changes in weight or mobility, effective measures were put in place to address any issues.

Everybody spoken with told us they enjoyed the food, they all said the food was good. People were offered choices and the food was nutritious and well presented. People who needed assistance with eating were supported in a dignified and unhurried manner. Some people chose to eat in their room.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.