St Catherines Care Home

People's experience of using this service and what we found

Improvements were needed to the governance systems within the service. There were failings by the provider in the way the service was led and managed. The systems in place for monitoring the quality and safety of the service were inadequate . They failed to identify and mitigate risk and bring about improvements to the service people received.

Records used to monitor, and review people's care had not been fully completed and kept up to date. We found examples where sections of care plans and care records had not been updated to reflect changes in their needs.

Staff were not recruited safely. Recruitment processes were not robust enough, staff files were disorganised and not always kept in one place; the registered manager told us they would work to improve the system.

Infection prevention and control practices were not always safe and did not protect people from the risk of infections. The kitchen was unclean and not well maintained.

Staff had not received all the training they needed to support people safely, for example safeguarding people from harm, infection prevention and control and managing fire safety.

We recommended the provider review their documentation in relation to end of life care and for the provider to ensure they support people to express their views and be involved in making decisions about their care.

We recommend the provider review how people are supported to maintain contact with relatives to avoid social isolation.

We received mixed feedback regarding staffing levels at the service. People, relatives and staff told us staffing levels were not always effective, particularly at weekends, to ensure people's needs were met in a timely way.

People and relatives told us staff were kind and caring and they treated them with dignity and respect.

People received their medicines as prescribed.

The registered manager was receptive to the inspection findings, they told us they were willing to learn, improve and share the actions that had taken or would take to address the issues found at this inspection .

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

This service was registered with us 12 October 2021 and this is the first inspection.

Why we inspected

This was a planned inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for St Catherines Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to monitoring and assessing risk, training, staff recruitment, infection prevention and control and oversight of the home.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St Catherines Care Home is a care home providing personal and nursing care for up to 40 people across two units, with one specialising in providing care to people living with dementia. At the time of the inspection there were 27 people using the service.

People’s experience of using this service and what we found

The service was registered under a new provider; Park Homes (UK) Ltd in October 2021. The transfer had not been well planned. The manager was new to the role and during this period there had been a lack of engagement from senior managers with limited induction for some staff. Governance and monitoring systems had not effectively identified the issues we found during the inspection. A recent COVID- 19 outbreak and staff shortages had significantly impacted on the service.

Whilst some risk assessments for people were in place, there was a risk people may be exposed to harm, as risks were not always fully considered and mitigated. When plans were in place to manage risk, it wasn't always clear these plans were being followed.

The provider was unable to demonstrate staff had been recruited safely in line with requirements. We could not be sure agency staff had the appropriate recruitment checks, competency and experience required to carry out their roles, as records were insufficient.

There were several staff vacancies and there had been staff absences, which were covered through a high usage of agency staff. The provider was actively recruiting for staff and the manager had recently arranged more consistent agency staff, which staff felt had been beneficial.

Risks in relation to COVID-19 had not always been effectively managed and we were not assured the provider had a robust system in place to check the vaccination status of staff and visiting professionals in line with government guidance. During the inspection the provider took immediate action to improve practice in relation to aspects of infection prevention and control (IPC).

People felt safe and able to raise any concerns. Staff told us they had received training in safeguarding; however, records were not up to date. The new provider had implemented eLearning and all staff were in the process of completing safeguarding training via this system.

People received their medicines safely and systems were in place to ensure medicines were ordered, administered and audited regularly.

Relatives had raised concerns about effective contact and communication with the service. The new provider had resolved some practical issues and the manager was working to improve communication.

People were involved in reviews of their care plans, which were being carried out. They told us care was provided in a way that suited their individual needs. Staff understood people’s care needs.

The registered provider and manager took responsive and prompt action during the inspection to mitigate risk and developed a detailed service improvement plan, to make the necessary improvements. They were open and transparent during the inspection.

Managers were working in partnership with other professionals such as the local authority and health colleagues to improve practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 10 October 2021 and this is the first inspection.

The last rating for the service under the previous provider was requires improvement, published on 22 October 2020.

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about the management of risk, staffing and infection control. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with infection control and the management of the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

As this is the first inspection under this provider, for those key questions not inspected, we have not awarded a rating and there is no overall rating. We have found evidence that the provider needs to make improvements.

Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Catherines Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the governance of the service, safe recruitment, the safe management of risk and COVID-19 vaccination as a condition of deployment.

The registered provider took responsive and prompt action during the inspection to mitigate risk and start to address the areas to improve the quality of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.