We inspected the service on 19 September 2018. The inspection was unannounced.

St John Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

St John Home is registered to provide accommodation, nursing and personal care for 18 older people and younger adults. It can also accommodate people who require support to manage their mental health and people who have physical and/or sensory adaptive needs. There were 15 people living in the service at the time of our inspection visit all of whom were receiving nursing care.

The service was run by a charitable body who was the registered provider.

At the last comprehensive inspection on 16 August 2017 and 18 August 2017 the overall rating of the service was, ‘Requires Improvement’. We found three breaches of regulations. This was because people had not always been provided with safe care and treatment. In particular, there were shortfalls in the steps taken to reduce the risk of accidents and to ensure that people drank enough and dined safely. There were also oversights in the checks made to ensure the safe operation of bed rails and pressure relieving mattresses. In addition to this, suitable provision had not been made to obtain people’s consent to the care they received. Furthermore, the registered provider had not established robust systems and processes to monitor, assess and improve the service.

We told the registered provider to send us an action plan stating what improvements they intended to make and by when to address our concerns and to improve the key questions of 'Safe', 'Effective' and ‘Well Led' back to at least, 'Good'. After the inspection the registered provider told us that they had made the necessary improvements.

At the present inspection we found that sufficient progress had been made to meet each of the breaches of regulations. There were robust arrangements in place to ensure that people reliably received the nursing and personal care they needed. This included lessons being learned when things had gone wrong so that arrangements could be made to reduce the risk of people experiencing falls. It also included people being helped in the right way to drink enough and to eat safely. Furthermore, additional checks had been made to ensure that bed rails and pressure relieving mattresses were in a serviceable condition. Revised arrangements had been made to enable people to seek consent in line with national guidance. Additional quality checks had been introduced to enable the registered provider to better ensure that people received care that met their needs and expectations. However, in relation to this more progress was still needed as quality checks had not identified that additional steps needed to be taken for the service to comply with a change in best-practice guidance. We found that people had not always had information presented to them in an accessible way. This had reduced their ability to receive person-centred care that promoted their independence. This was because appropriate arrangements had not been made to implement the Accessible Information Standard 2016. We have made a recommendation in relation to this matter.

Our other findings were as follows: People were safeguarded from situations in which they may experience abuse including financial mistreatment. Medicines were managed safely. There were enough nurses and care staff on duty. Background checks had been completed before new nurses and care staff had been appointed. Suitable arrangements were in place to prevent and control infection.

People received nursing and personal care that was delivered in line with national guidance by nurses and care staff who had the knowledge and skills they needed. This included respecting people’s citizenship rights under the Equali

This unannounced inspection took place on 16 August 2017. We returned to the service to finish the inspection on 18 August 2017.

The St. John Home is owned by St John’s Ambulance. It has a charitable status and therefore is non-profit making. Accommodation is over two floors with a stair lift to the first floor. The service provides residential and nursing care with accommodation for up to 18 older people.

There was registered manager working at the 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 and associated Regulations about how the service is run. The registered manager had been in post since March 2017. As the service is a nursing home there is always at least one a registered nurse on duty 24 hours a day.

Some risks had been identified to people's health and welfare but full guidance to make sure all staff knew what action to take to keep people safe and manage risks was not always available. For example, when people were at risk of falling, or not drinking enough, or when their skin was at risk of breaking down the risk assessment did not contain the information needed to make sure risks were mitigated. This left people at risk of not receiving the support they needed to keep them as safe as possible. Accidents and incidents had been recorded but there was no analysis or oversight of the accidents and incidents. Triggers, patterns and interventions had not been identified to try and reduce the risk of re-occurrence.

The registered manager and staff carried out environmental and health and safety checks to ensure that the environment was safe and that equipment was in good working order, however some checks and audits had not been completed. When shortfalls had been identified, action had not been taken to reduce risks and make improvements. When the water temperatures were recorded as exceeding the recommended limits action had not been taken to make sure they were safe. The provider had sought feedback from people but had not analysed the results. They had not asked relatives, staff and other stakeholders for their views so that improvements could be made.

People, staff and relatives told us that the service was well led and that the registered manager was supportive and approachable. However, the registered manager did not have full oversight and scrutiny of the service. They were not effectively supported by the provider’s systems and processes. The registered manager was developing a culture of openness and transparency within the service.

Emergency plans were in place so if an emergency happened, like a fire, staff should know what action to take. Not everyone’s personal evacuation emergency plans (PEEPS) contained all the information to explain what individual support people needed to leave the building safely. Regular fire drills had not taken place. During the inspection we contacted the fire officer to tell them of our concerns. A fire safety company had recently visited the service and remedial work had been undertaken on the emergency lighting and extra smoke detectors had been fitted.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The registered manager was not fully aware of a judicial review which widened and clarified the definition of a deprivation of liberty. The registered manager and staff had a lack of understanding about their responsibilities under the Mental Capacity Act 2005 and DoLS. Mental capacity assessments had not been consistently completed by the staff to decide whether or not people were able to make decisions themselves. At the time of the inspection the registered manager had not applied for DoLs for people who may need them. When people