Archived: St Augustine's Care Home

St Augustine’s Care Home is a residential care home providing accommodation and personal care to up to 52 people. The service provides support to older people with physical and health related support needs, some of who also live with dementia. At the time of our inspection there were 39 people using the service.

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

Although people told us they liked living in the home, felt safe and staff were caring, the multiple changes in the management resulted in inconsistent leadership. Incidents, accidents and safeguarding concerns were not always used to learn lessons and to improve the service. Staff did not always receive the training they needed to ensure they were competent and skilled for their roles.

Staff told us they did not read care plans and relied mainly on verbal handover within the team and from management. Staff knew people’s individual risks and we observed they supported people in line with their individual needs but people’s care records were out of date and did not always accurately address all of their needs. This posed risk of people’s care not being effective and safe at all times, especially when the home experienced staffing challenges and was supported by agency staff.

There was a lack of structured approach to monitoring the quality of the service. The provider completed some audits of the safety and quality of the care people received and their home environment, but their management contingency action plans failed to effectively action shortfalls these audits identified. The provider and new management team took action to address these shortfalls following the inspection.

Staff ensured people could access healthcare services when they became unwell or their needs changed and they required specialist support. People received their medicines safely and were supported to eat and drink when they needed help.

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.

People told us they felt listened to and overall could access support from staff when they needed it. Staff considered things had been improving since the new management started to lead the team and felt the management were approachable and supportive. The provider worked in partnership with other agencies, including social and health services in the area.

For more details, please see the full report which is on the CQC website at St Augustine’s Care Home.

Rating at last inspection

The last rating for this service was good (published 5 April 2018). We also inspected this service on 28 February 2022 and looked at the infection prevention and control practices only.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements in Safe, Effective and Well-Led.

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

The provider and the new management team took action to update their management contingency plans and improvement action plan and to provide staff with support to complete relevant training courses.

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

Enforcement

We have identified breaches in relation to staff training and good governance at this inspection.

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.

We found the following areas of good practice

Current government guidelines in relation to COVID-19 were being followed by staff and visitors to reduce the risk of infection to people living at the home. This included comprehensive checks for visitors on arrival.

Some communal areas of the home had been renovated and refurbished during the COVID-19 pandemic to provide additional spaces for people to receive visitors and reduce the risk of the spread of infection.

When there had been people who had tested positive for COVID-19 the management had arranged for these people to be supported by separate staff to the other people living at the service. This helped to reduce the risk of COVID-19 transmission around the service.

Cleaning had increased during the COVID-19 pandemic and frequently touched surfaces such as light switches were cleaned regularly throughout the day to reduce the risk of infection. There were hand sanitizer dispensers readily available around the home.

This inspection took place on 21 February 2018 and was unannounced. There were 48 people living at the service at the time of our inspection.

We previously carried out an unannounced comprehensive inspection of this service on 1 February 2017 when we rated the service as Requires Improvement.

The last two years have been a period of considerable change at St Augustine’s with significant management and staffing changes having taken place. Since July 2016, a management team have been running the service whilst seeking to find the right manager to take over the role. In January 2018, a new manager was appointed and is currently in the process of applying for registration. 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.

Despite having only been in post for five weeks at the time of this inspection, the feedback we received from people, relatives, staff and other professionals was that the new manager was a good appointment. She was working well with the management team and collectively they had produced a development plan for the service. The culture of the service was open and positive and what the service needs now is a period of stability for the changes to be embedded and sustained.

The management team had successfully recruited a team of permanent staff and as such people were now being supported by sufficient staff who knew them. Appropriate recruitment checks had been undertaken to ensure suitable staff were employed. A bespoke programme of induction and training enabled staff to have the skills and support to deliver their roles effectively.

There were appropriate systems, processes and practices to safeguard people from abuse. Risks to people were identified and managed safely whilst allowing people the freedom to live the lives they chose.

People’s needs and choices had been better assessed to ensure support was delivered in a way that achieved effective outcomes. Assessment information was then used to form individualised plans of care so that people were supported in a person centred way.

People were supported to lead healthy lives and encouraged to eat and drink so as to maintain a healthy and balanced diet. Staff worked collaboratively and in partnership with other healthcare professionals to ensure people received holistic personal and health support. The management team were taking continuous steps to ensure medicines were managed safely and that people received their medicines as prescribed.

The environment was adapted and decorated for the purpose of the services provided. The service was clean and improvements to the management of infection control had recently improved significantly.

The atmosphere in the service was relaxed and friendly and people’s emotional and spiritual needs were met. People had opportunities to engage in activities that were meaningful to them. People had good relationships with the staff who supported them with genuine compassion and care.

People were involved in making decisions about their care and staff understood the importance of respecting people’s choices and individual preferences. Staff had a better understanding of people’s capacity and were being more proactive in the way they protected people’s legal rights.

There were effective systems in place to ensure that people were listened to and concerns were addressed in a way that improved the quality of care. A culture of reflective learning was growing across the service to ensure lessons were learned and feedback was used to secure improvements.

Staff respected people’s privacy and took appropriate steps to ensure their dignity was upheld. End of life care enabled people’s final wishes to be respected and allowed people to pass with dignity and peace.

This inspection took place on 1 February 2017 and was unannounced. There were 48 people living at the service at the time of our inspection..

We previously carried out an unannounced comprehensive inspection of this service on 28 June 2016. At that inspection a number of breaches of legal requirements were found. As a result the service was rated Inadequate overall and the provider was placed into Special Measures by CQC. As part of this decision, we met with the provider to discuss our concerns. We also issued two Warning Notices which required the provider to take immediate action in relation to staffing levels, and the effective governance of the home.

Since our last inspection we have continued to engage with the provider. We required the provider to submit regular action plans that updated us about the steps they had taken to improve the service. We also asked the provider to submit us copies of weekly staffing information and provide assurances that safe staffing levels had been maintained. This inspection confirmed that the provider had taken the action they told us they had. Significant improvements to the way the home was being managed meant that the provider had complied with the Warning Notices we had issued and we have now taken St Augustine’s Care Home out of Special Measures.

The service did not have a registered manager in post. 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. The previous registered manager had not been working in the service for a number of months and their registration has now been cancelled with us. The day to day management of the home was being undertaken by the registered manager of one of the provider’s other services who had been based at the service since July 2016.

There has been a period of considerable change at St Augustine’s over the last six months. Whilst it was evident that the quality of care had significantly improved, the leadership of the home now needed to be embedded and sustained through the recruitment of a permanent manager and strengthening of the staffing team.

The provider had maintained safe staffing levels through the provision of agency staff. Considerable efforts had been made by the management team to ensure wherever possible the same agency staff were used and they were appropriately inducted to the service. Appropriate checks were undertaken to ensure only suitable staff were employed. The provider also had also introduced systems to improve the vetting of temporary staff.

Through the use of one page profiles and detailed handovers, information about how to effectively support people was made available to staff who were less familiar with their needs. Whilst it was clear that the management team was taking every effort to provide consistent and safe care, the number of different staff supporting people, was still having some effect on the quality of care that people received.

The changes to the staffing team meant that the supervision and development of staff was at the start of an ongoing journey. Mandatory training was up to date and staff were now in the process of undertaking more bespoke learning in order to develop the necessary skills to support people effectively.

People were safeguarded from the risk of harm, because staff now understood their roles and responsibilities and knew where to go if they had concerns. The acting manager had introduced better systems to assess and manage the risks to people.

People’s legal rights were better protected and staff ensured that they gained consent before delivering care. Where people lacked capacity to make decisions for themselves, there were processes in place to support people in line with their best interests. Whilst not all staff fully understands the principles of the Mental Capacity Act, there was a general awareness for people to be offered choice and for support to be delivered in the least restrictive way.

The management team were taking continuous steps to ensure medicines were managed safely and that people received their medicines as prescribed. Staff worked in partnership with other healthcare professionals to ensure people’s needs were met in a more holistic way. People’s medical needs were better assessed and now subject to on-going review to ensure that they received the most appropriate care. People received more personalised support and had opportunities to spend their time doing things that were meaningful to them.

People had choice and control over their meals and were effectively supported to maintain a healthy and balanced diet. Where people had specialist dietary needs, these were known and respected. Assistance at meal times was provided with dignity by staff who knew people’s preferences.

The atmosphere in the service was relaxed and friendly and people’s emotional and spiritual needs were met. People had positive relationships with the staff who supported them and were now treated with kindness and in a way that respected their privacy and dignity.

People and their representatives were actively involved in making decisions and choices about their care. Both people and their relatives said they now felt confident about expressing their feelings. The provider took appropriate steps to ensure that any concerns or issues raised were listened to, treated seriously and resolved in a timely way.

The inspection took place on 28 June 2016 and was unannounced. There were 52 people living at the service at the time of our inspection. Due to new concerns raised during the feedback calls made after our visit, we sought additional information from the provider which has also been included in making our judgements within this report.

The service had 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 had been in post since November 2015.

We previously carried out an unannounced comprehensive inspection of this service on 18 June 2015. At that inspection a number of breaches of legal requirements were found. As result the service was rated Requires Improvement in all domains and five requirement actions for the service to improve were set. Following that inspection, the provider sent us an action plan which identified the steps they intended to take to make the required improvements. Despite telling us that the requirement actions would be addressed, we found two continued breaches of regulations at this inspection.

Since the last inspection we have received a number of concerns from visiting professionals, relatives and staff about the services provided at the service. Some of these concerns are continuing to be investigated through a safeguarding investigation with our partner agencies. As this investigation has not yet concluded, we are unable to include specific details within this report.

Information gathered both through the on-going investigation into St Augustine’s Care Home and this inspection, has highlighted some serious concerns with both the staffing and management of this service.

We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have taken enforcement action and issued Warning Notices in relation to staffing and quality monitoring. You can see what action we told the provider to take at the back of the full version of the report.

Our last inspection highlighted that staffing levels were not sufficient to meet people’s needs. The provider told us that they had reviewed the number of staff required and increased staffing levels accordingly. During our visit to the service on 28 June 2016, there were more staff on duty. Some staff told us that the number of staff on duty that day were not typical of the usual staffing levels in the service The management team assured us that they had recently increased staffing levels and that the number of staff on duty that day were representative of how the service was now being staffed.

Following our visit, we received new information that the staffing levels we observed had not been maintained. We therefore contacted the provider and requested that they submit their rotas to us. From this information, we saw that staffing levels had not been maintained to the minimum level determined by the registered manager as being safe on any day since our visit. On three separate occasions the service was staffed with less than half the number of care staff required.

Our last inspection identified that risks to people were not always adequately assessed and managed. Whilst the areas that were previously of concern had been addressed, people were still not properly protected by the risks relating to their care. In particular, the management team had failed to take appropriate action when people’s needs had increased beyond the skills and expertise of staff and this had placed people at the risk of harm.

Whilst staff spoken with during our inspection highlighted that they understood their roles and responsibilities in relation to safeguarding, they had not always acted appropriately. The safeguarding investigation regarding the service also highlighted significant shortfalls in the way the service safeguards people. The management team delayed the on-going safeguarding investigations as they did not always provide sufficient and accurate information both to ourselves and our partner agencies.

Our last inspection also raised concerns about staff not having a good understanding of the Mental capacity Act and Deprivation of Liberty Safeguards and consequently people were not previously receiving care in the least restrictive way. At this inspection we found that staff had a better understanding of these areas and greater steps had been taken to ensure that people were not restricted without proper assessment and consent. Concerns were however raised through the on-going safeguarding investigations about the management team’s understanding of the formal processes in this area which were directly relevant to their role. Delays in assessing and recording people’s decisions about their end of life care did not adequately ensure that people’s wishes were respected.

Our last inspection found that people living with dementia did not always have choice and control over their daily routines. We also noticed last year that people living with dementia were not always treated in a way that fully protected their privacy and dignity. At this inspection we saw that the provider had provided additional training to staff to improve their understanding about how to effectively support people living with dementia. We observed at this inspection that people were supported in a more respectful way and offered better opportunities to lead more meaningful and fulfilling lives.

In addition to looking at the concerns raised at our previous inspection, this visit also identified some new areas of concern. For example, the provider had told us that they had improved care records; however we found that care plans were still in the early stages of being updated. Whilst the care plans that had recently been updated had been completed to a good standard, it is of concern that this work was still outstanding a year after the shortfalls were identified. Care staff were providing care to some people without appropriate guidelines and risk assessments being in place and this placed people at the risk of receiving inappropriate and unsafe care.

Following concerns highlighted through the safeguarding investigation, the provider had taken steps to improve the management of medicines. Whilst we found at this inspection that people had recently received the right medicines at the right times, the systems in place to manager and monitor were not wholly safe. For example, important information about people’s allergies to certain medicines was not readily available. Records relating to the auditing, storage and safety of medicines were incomplete and staff were not able to demonstrate that these areas were managed safely.

Staff had not always received the training and support to deliver their roles appropriately. Where staff had completed on-line training, this had not been followed up with competency checks to ensure this learning was effective and embedded. The provider had a policy for new staff to receive a two-week induction in which they shadowed other staff, but for the newest member of staff this had not happened. Over the last 12 months the needs of people living at the service had increased and new people with more complex medical needs had been admitted to the service. The provider had failed to ensure that staff had the necessary skills and experience to support these people appropriately.

The management of the service presented as chaotic with key information either not being available or in place but incomplete. The management team were not proactive in their leadership and had failed to competently deliver the service in a way that protected the well-being and safety of people. Internal monitoring and auditing had failed to properly identify and address the concerns repeatedly raised by professionals and where issues were addressed, this had not been done in a timely way. The provider submitted an urgent action plan in response to our verbal feedback on the day of our inspection which addressed some of the issues raised, but our subsequent engagement with them about staffing levels and risk management identified that this action plan could not be wholly relied upon.

There was a complex culture within the service and it was not always possible to evidence who was ultimately in charge. Care staff did not always feel their contribution was valued and the turnover of care staff within the last 12 months had been high. Some relatives said that whilst they knew how to complain, they did not always feel fully comfortable in doing so.

The service had systems in place to ensure people were suitably vetted at the point of recruitment. In addition to care staff, people were also supported by a team of religious sisters who provided assistance at mealtimes, offered activities and led prayer. Many people and their relatives told us that they received a great deal of emotional and spiritual comfort from the service.

Efforts had been made to improve the activities available to people, although activities were most meaningful for those people with higher levels of ability and cognition. The provider had taken steps to better engage with people living with dementia and help staff to understand the person behind the needs.

People enjoyed their meals and mealtimes were observed to be a social occasion where most people dined together.

The overall rating for

During our follow up visit we spoke with three people and one relative. We also looked at records and spoke with five staff including the manager of the service.

We saw that the atmosphere of the home appeared relaxed and there were enough staff on duty to meet people's needs. We saw that improvements had been made to both staffing and the environment. For example, a library had been created for people to use and more care staff had been employed.

People we spoke with told us that 'The care is very good' and confirmed that there were always enough staff and volunteers to help them.

Staff we spoke with told us that they felt supported by the manager and we saw that staff worked together well.

We saw that record keeping had improved and care plan records were up to date.

We spoke with nine people and three relatives and conducted observations throughout the visit. Many people who used the service were unable to communicate well with us due their mental frailty but we saw that carried out observations throughout our visit.

We looked at records and spoke with five staff including the area manager of the service.

We saw that staff spoke with people respectfully and the atmosphere of the home appeared relaxed.

We saw that activities took place in the morning and that people were walking or sitting in enclosed gardens during the afternoon.

People told us that they felt safe and that staff were kind. Staff had received recent safeguarding training.

We saw that the home was clean and well maintained.

There were mixed views from people about the level of staffing and two people and their relatives commented negatively about waiting for staff to assist.

We saw that appropriate training and supervision was not always provided to support staff in their role. We also saw that care records were not always up to date.

During the follow up inspection visit we spoke with four people who used the service. We carried out an observation using a specially designed tool over half an hour during the resident's lunch. This tool enabled us to gather information through observations about the welfare of people who may not have been able to provide responses to our questions. We also conducted observations and saw that both staff and volunteers helped people at a relaxed pace. We observed that people were gently encouraged and spoken to softly and respectfully.

We asked people what they thought about the care that they were given and each person told us that they were happy with the care provided and that staff and volunteers were kind and helpful.

Two people commented on the staff, one saying to us, they 'look after me very well.' Another person said 'I admire the staff.'

During our discussions people indicated to us that they were happy living at the home and that their individual needs were met. One person said of the staff and volunteers 'they always make allowances for me.' Another person told us that 'they are all very kind.'