This inspection took place on 6, 8 and 10 September 2018 and was unannounced.

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

St Johns Nursing Home accommodates up to 38 people in one adapted building over two floors. There were 25 people at the service at the time of inspection. People living at the service were older persons with nursing care needs, some of whom were living with dementia.

At our last inspection in January 2018, we found widespread shortfalls within the safety and governance of the service. We identified seven breaches in six regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. The home received an overall rating of inadequate and was put in special measures.

We issued warning notices for more serious breaches of Regulations 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and requirement notices for the other regulations breached.

Following the last inspection, we met with the provider and imposed four conditions on their registration. This helped us monitor the progress of improvements made to help ensure the safety of people living at the service. The provider sent us regular action plans and audits to demonstrate how they had made and sustained required changes. We also stipulated that the provider required written permission from CQC before admitting new people to the home.

The service did not have registered manager in place at the time of our inspection. 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. Since the last inspection, the registered manager had left and no longer worked for the provider. The new manager had been in place since February 2018. At the time of inspection, their application to register as manager with CQC was in progress.

The manager had overseen significant improvements since the last inspection. The provider had met the requirements of the regulations which were breached at our last inspection.

There was a clear governance structure within the service, staff understood their roles and there was a calm and organised atmosphere in the home. The manager had implemented effective systems to oversee the quality and safety of the home. They had formulated and implemented plans to make improvements to areas which needed addressing and used audits and checks to assesses how effectively these changes had been embedded.

The provider had worked with different stakeholders to identify issues and put in place plans to make improvements. We received positive feedback from health and social care professional about how the service was managed.

People, relatives, staff and professionals told us that that the manager had instilled a positive culture at the service and that she was professional and approachable. The manager listened to complaints and feedback, using them to identify how improvements could be made.

However, we identified a breach in regulation around the provider’s recruitment processes. The provider did not always ensure that the required recruitment checks were carried out before staff started working at the service.

There were enough staff in place to meet people’s needs. The provider had recruited permanent nursing and care staff to decrease the reliance on agency workers. Staff were supported with appropriate training and ongoing support in their role.

Staff were compete

This inspection took place on 15, 16 and 19 January 2018 and was unannounced. The home provides accommodation for up to 38 people with nursing care needs. There were 32 people living at the home when we visited, some of whom were living with dementia. All areas of the home were accessible via a lift and there were three lounge/dining rooms spread across both floors. There was accessible outdoor space from the ground floor. Bedrooms were a mix between single and shared occupancy.

St John’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.

There was a registered manager at the home. 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.

At our last inspection in December 2016, we identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to send us an action plan detailing how they would make improvements in the areas of: ensuring the service obtained appropriate consent to provide people’s care, and ensuring there were sufficient numbers of trained and qualified staff in place. At this inspection we found the provider was still not meeting the requirements of these regulations and we also found concerns in other areas.

There was no clear management structure in place. The provider did not have management or supervisory staff in place who were able to assume roles in overseeing the quality and safety of the service. As a consequence, there were deficiencies in key areas of the running of the service, which resulted in the compromised safety and wellbeing of people. The registered manager had worked hard in their role to make improvements, but told us they often did not have the resources to fully implement or imbed improvements.

People’s medicines were not managed safely. The medicines management system in place did not ensure effective, ordering, storage, administration, recording or disposal of people’s medicines. This put people at risk of harm as there were examples where people received the incorrect medicines or it was not clear which medicines they were prescribed to receive.

Risks to people’s individual safety were not managed effectively to reduce the risk of harm. Systems and plans to protect people in the event of an emergency were either not completed or did not fully consider the most effective action to take in order to keep people safe. Where risks had been identified around people’s health conditions, monitoring and management plans were put in place in order to manage these conditions. However, the actions and recordings related to these plans were not always clearly followed, which resulted in confusion about the support people had received and how effective treatment plans were. There were ongoing safeguarding concerns in relation to people’s health and wellbeing which the registered manager was investigating at the time of inspection.

There were enough staff working in the home, but staffing levels were maintained only with the addition of agency staff. The registered manager told us they were in the process of recruiting staff, but the service had experienced a high turnaround of staff leaving since our last inspection. Staff’s ongoing training and development needs were not closely monitored. Many staff required training updates to ensure their knowledge was current and following best practice.

People did not always receive personalised care. Care plans did not contain sufficient detail to enable staff to understand people’s behavioural and communicati

The inspection took place on 5 December 2016 and was unannounced. We returned on 8 and 14 December 2016 to complete the inspection.

We had major concerns during our last two inspections of St John's Nursing Home and we found at these times St John's Nursing Home was providing inadequate care treatment and support .This meant the service had been placed into 'special measures' by CQC.

The owners of the service have been very responsive about putting things right and have worked cooperatively with commissioners of services to improve standards. They benefitted from support and advice provided by staff from Hampshire County Council and staff from the CCG.(Clinical Commissioning Group)

St Johns Nursing Home is registered to provide care, treatment and accommodation for up to 38 people. At the time of our visit 24 people were living there.

There was not a registered manager in post although the provider had submitted an application for two senior staff to share this role.

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.

At this inspection we found there had been significant improvements to the care and treatment provided to people who lived at St John's. This meant we judged St Johns was providing much better care to the people living there although we found further improvements were still needed.

Improvements needed included consistently employing sufficient numbers of staff to meet people's needs. Staff also needed to consistently enact the Mental Capacity Act 2005 to ensure they upheld people's rights. Staff had a good understanding of people's needs and the risks associated with their care but this information needed to be more consistently recorded. When people were admitted assessments had to be done in a more timely way to help to ensure staff were aware of people's care and treatment needs.

People were cared for by a dedicated and hardworking staff team who knew them well. Staff had worked very hard to improve the service and this had been recognised and appreciated by management. Staff were provided with support and training and nursing staff were given clinical supervision to ensure their professional skills were maintained.

People's nutritional needs were known and adhered to. Staff worked cooperatively with health care professionals to ensure health care needs were understood and met. The service had employed an activity coordinator which meant people had more individual and social interaction.

We undertook an unannounced focused inspection of St John’s Nursing Home on 18 August 2016 as a result of concerns raised during our previous inspection in April 2016. We inspected the service against one of the five questions we ask about services: is the service Safe?. This inspection was completed as we wanted to follow up on some of the concerns we had regarding the care provided to people living at the home. These included identified shortfalls relating to good governance. In April 2016 we had found the service had not identified significant issues relating to the safety, care and welfare of people who lived at the service. We also found they did not have effective processes in place to monitor and mitigate the risks to service user’s health and wellbeing.

We carried out an unannounced comprehensive inspection of this service in April 2016 where seven regulatory breaches were identified. Following the inspection the provider wrote to us to say what they would do to meet these legal requirements. They were also working with health and social care professionals who were providing advice and support in improving the service. We met with the provider to discuss our concerns and wrote to them to provide further details about how they were failing to comply with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance. We told them they were required to become compliant with Regulation 17 by 31 July 2016.

The purpose of this focused inspection was to determine whether the provider had become compliant with Regulation 17 of the Health and Social Care Act 2008 Regulated Activities) Regulations 2014. These were the areas we had found which most compromised people’s health and safety. We will follow up all other areas of non-compliance which were detailed in our report of April 2016 at our next unannounced comprehensive inspection of the service.

St Johns Nursing Home is registered to provide care treatment and accommodation for up to 38 people. At the time of our visit 29 people were living there. There were nine double rooms. The home had a registered manager in post although they had tendered their resignation. 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.

Although overall we found the environment to be calmer with people’s requests for support answered in a more timely way, the provider continued to be in breach of Regulation 17 of the Health and Social Care Act 2008. (Regulated Activities) Regulations 2014 as they had had not made consistent improvements to ensure people’s safety and welfare. We were not satisfied people always had enough to drink, and we were not satisfied people were protected against the risk of scalding. We did not see sufficient evidence that staff had suitable skills to care for people with diabetes or for people at risk of choking.

Staff did not manage wounds in line with NICE (National Institute for Health and Care Excellence) guidance and there were no validated pain assessments in place to ensure people received pain relief when they needed it.

This inspection took place on 25 and 27 April 2016 and was unannounced.

Our previous inspection had taken place in January 2015. At this time we judged overall that the service required improvement before it could demonstrate it provided consistently safe, effective, caring and responsive care. As a result of shortfalls in all these areas we concluded that they also needed to make improvements in the leadership of the home. We said there were two breaches in legislation, these related to the management of medicines and systems and processes relating to good governance. At this inspection we found the required improvements had not been made and there were other shortfalls which also constituted breaches in regulation. These related to the way the service safeguarded people from possible abuse or neglect, the way in which they identified and managed risks, particularly to people's health, and the way they gained people’s consent to their care and treatment. We found staffing levels were not always adequate to meet people’s needs. Some elements of the delivery of service were task centred which had an impact upon how well the service could demonstrate it was providing care which always met the needs and preferences of the people living at St John's.

St Johns Nursing Home is registered to provide care treatment and accommodation for up to 38 people. At the time of our visit 36 people were living there. There were 9 double rooms. Since our last inspection a new registered manager had been employed.

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 not a nurse. She was supported by a registered nurse who was head of clinical Care. The registered manager demonstrated that had understood some of the shortfalls within the home but action taken had yet to have an impact upon the overall quality of the service.

Some people were happy with the quality of care and support they were being provided with and health care professionals and relatives all provided positive feedback when they were surveyed about the quality of care and treatment people received. The complaints procedure had improved.

We witnessed some kind and caring interaction between staff and people who lived at the service. However the service continued to have significant shortfalls which at times put people at avoidable risk. You can see what action we told the provider to take at the back of the full version of the report.

Special measures.

The rating for this service is 'inadequate'. This means that the service has been placed into 'special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conduc

We found that people had their own topical creams in their rooms and that the bottles were labelled clearly. There was an audit system in place which meant people's medication could be accounted for. The sharps bins were being used appropriately.

We visited St John's Nursing Home to monitor compliance with a compliance action we set regarding medication. We did not speak with people about medication on this occasion. We found that some people had prescribed topical creams and other prescribed items in their bedrooms which belonged to other people. We also found some people had topical creams without a name on the label.

We looked at how the medication was audited with regard to stock numbers for three people. Records matched the numbers of tablets accurately for one person but not the other two.

Used needles were not stored safely, although they were locked away from people living in the home.

We found St John's Nursing Home was not compliant with this outcome.

People told us they could make choices about how they spent their day. A person told us the staff were nice and talked them through what they were going to do. People told us that staff supported them with personal care in the way that they needed and wanted. They also told us that they could use the call bell for assistance and staff were prompt in responding. Visitors also confirmed this. We were told that staff met individual needs and responded to changing needs and contacted relatives if someone was unwell. Visitors told us that staff were nice, friendly and, ‘constantly around’.

Residents told us they enjoyed the food and that there was a choice. They also told us they were happy with where they were sitting for lunch. A relative told us that their relative was supported with their meals and that food was presented in the way they needed it to be. The relative also said they had seen plenty of drinks in the home.

A resident told us they were given their medication when they needed it.

We were told by a resident that the home was kept clean and their bedroom was cleaned every day.

This inspection took place on 19 and 26 January 2015 and was unannounced. At the time of our inspection 31 people were living at St John’s Nursing Home.

Our last inspection took place in February and March 2014. At that time we found the service needed to make improvements in infection control, in the management of medicines, specifically in how medicines were stored and in the way people understood how they could complain. At this inspection we found improvements had been made in these areas.

St John’s Nursing Home is situated on the outskirts of Southampton. It is registered to provide care support and treatment for up to 34 people. This included some people who are living with dementia. There were building works going on when we visited which will improve the bathing and communal facilities for people.

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 and has the legal responsibility for meeting the requirements of the law; as does the provider.

During this inspection we found two breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which now corresponds to breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the management of medicines and the way in which the service managed quality assurance. You can see what action we told the provider to take at the back of the full version of this report.

Improvements were needed to ensure staff consistently followed the principles of the Mental Capacity Act 2005 (MCA). Information was not always handed over effectively when shifts changed. Care planning information needed to be updated as people’s needs changed.

There was a stable staff team who knew and understood people’s needs. Staff worked in collaboration with health and social care professionals to improve people’s experience of care, treatment and support.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA and relates to promoting people’s rights to freedom of movement. We found the home was following the correct DoLS procedures.

Staff suitability was checked at recruitment to ensure they were safe to work with older people. Risks were identified and managed. The home was staffed with enough care workers to meet people’s individual needs and staff received training relevant to their roles.

Staff demonstrated a caring and friendly manner. They also supported people to maintain relationships with friends and relatives.

Support was provided to maintain or improve people’s health and wellbeing, through regular appointments with health professionals such as GPs.