St Claire's Care Home

We found the following examples of good practice.

¿ Due to the outbreak of COVID-19 the service was closed to visitors in accordance with Government guidelines.

¿ Staff supported people to use the communal areas of the service in a way which supported social distancing.

¿ There was prominent signage and instructions to explain what people should do to ensure safety in accordance to the use of PPE (personal protective equipment).

St Claire's Care Home is a residential care home providing care and accommodation care to 24 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 39 people. The accommodation is provided in one adapted building which is located near to the town centre.

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

People felt safe living at the service. Risks to people were well managed by a staff team who understood people’s needs well. People were protected from the risk of abuse and there were appropriate systems in place to safeguard people.

Medicines were well managed which meant people received their medicines as prescribed. People were happy with the support they received with their medicines including support to manage any pain.

People were supported by sufficient numbers of staff who had the skills and knowledge they needed to support people well. Staff had time to chat to people and people were positive about them. New staff had been recruited safely and pre-employment checks had been carried out.

People told us they were happy with the care they received. They told us they were treated with respect, kindness and compassion. People’s privacy was respected, and they were supported to lead dignified lives. Staff knew people well and care was provided in a person-centred way which respected people’s individual needs.

People were supported to maintain their independence and continue to do things for themselves where possible. Where appropriate, people went out independently or were supported to do so. 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.

Staff supported people to maintain their health and wellbeing. People confirmed they had access to healthcare services when they needed this. People were positive about the food and were supported to maintain their weight and stay hydrated.

People were encouraged to express their views and told us they felt listened to. There were systems in place to seek feedback from people, relatives and health and social care professionals and improvements were made to the service where appropriate.

The service was clean and the environment pleasant and welcoming. The environment had been adapted to meet people’s individual needs and was suitable for people living with dementia.

Staff were aware of infection control and the appropriate actions had been taken to protect people from harm.

People benefited from their care being provided by a well-led service which had continued to improve. Staff, relatives and health and social care professionals told us the service was well managed. Staff were supported, happy and motivated and this led to their being a positive atmosphere at the service.

There were regular audits to identify where improvements were needed, and action had been taken to address any concerns found. Staff understood their responsibilities to raise concerns and incidents were recorded, investigated and acted upon. Lessons learnt were shared and trends were analysed. The service worked in partnership with other agencies learn and share best practice.

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

Rating at last inspection

The last rating for this service was Requires Improvement (published 11 July 2018). There were no breaches of regulation and we did not ask the provider to complete an action plan.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St Claire’s Care Home is registered to provide accommodation and personal care for 39 older people and people who live with dementia. There were 20 people living in the service at the time of our inspection visit.

The service was run by a company who was the registered provider. The company was formed of two directors both of whom were present during our inspection visit. 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. In this report when we speak about both the company’s directors and the registered manager we refer to them as being, ‘the registered persons’.

At the last comprehensive inspection on 30 August 2017 the overall rating of the service was, ‘Inadequate’ as a result of which the service was placed into ‘special measures’. We found that there were six breaches of the regulations. This was because there were shortfalls in the arrangements that had been made to provide people with safe care and treatment. This included instances when accidents and near misses had not been managed in the right way so that lessons could be learned to help prevent a recurrence. People had not been fully safeguarded from the risk of abuse and sufficient numbers of suitably qualified care staff had not been deployed. There were also shortfalls in the way that people were provided with person-centred care including providing them with sufficient opportunities to pursue their hobbies and interests. Another oversight related to defects in the accommodation. A further shortfall was in the arrangements used to monitor and improve the service including consulting with people to obtain feedback about suggested improvements.

We told the registered persons to send us an action plan stating what improvements they intended to make to address our concerns. After the inspection the registered persons told us that they had made the necessary improvements.

At the present inspection we found that sufficient progress had been achieved to meet all of the breaches of regulations. Suitable provision had been made to provide safe care and treatment and people were safeguarded from situations in which they may be at risk of experiencing abuse. Enough suitably qualified care staff had been deployed. Although people received practical assistance that met their expectations, further progress was needed to ensure that all of care provided was person-centred. A significant number of improvements had been made to the standard of the accommodation although more still needed to be done to address defects in the fabric of the building. The systems and processes used to assess and monitor the operation of the service had been strengthened, although further improvements were needed to ensure that progress in the service was sustained.

Our other findings were as follows. Some pre-employment background checks on new care staff had not been completed in the right way. Although most medicines were managed safely an improvement needed to be made to the way in which one category of medicines was administered. Suitable provision had been made to promote good standards of hygiene in order to prevent and control the risk of infection.

Appropriate arrangements were in place to assess people’s needs and choices so that care was provided to achieve effective outcomes. This included providing people with the reassurance they needed if they became distressed. Care staff knew how to care for people in the right way and had received training and guidance. People were helped to eat and drink enough to maintain a balanced diet. Suitable provision had been made to help people receive coordinated care when they moved between different services. People had been supported to access all of the healthcare services they needed. Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance.

People were given emotional support when it was needed and they had been supported to express their views and be actively involved in making decisions about their care as far as possible. This included them having access to lay advocates if necessary. Confidential information was kept private.

There were systems and processes for managing complaints and suitable steps had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

There was a registered manager who had promoted an open and inclusive culture in the service. Suitable arrangements had been made to ensure that regulatory requirements were met. The registered persons were actively working in partnership with other agencies to support the development of joined-up care.

St Claire's Care Home is a large house, previously arranged as three attached houses, now converted to a single property. People's bedrooms were provided over four floors, with a passenger lift providing stair free access. There were communal sitting rooms and a communal dining area. There was an enclosed area of garden at the front of the property.

A registered manager was 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.

We carried out an unannounced comprehensive inspection of this service on 27, 28 and 31 October 2016 and St Claire’s was rated ‘Requires Improvement’ and ‘Inadequate’ in the ‘Safe’ domain. There were breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. We issued requirement notices relating to safe care and treatment, staffing, need for consent, premises and equipment, person centred care and good governance. We asked the provider to take action and the provider sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. The provider had not met the previous breaches of regulations and further breaches were found.

Risks relating to people’s care and support were not always assessed or mitigated. Staff told us and we observed that some people could become distressed and display behaviours that challenged. This was not always documented and there was no guidance for staff on how to prevent this from happening. Accidents and incidents were not investigated or analysed to look at ways of reducing the risk of them happening again.

The environment was not always safe. At our previous inspection we asked the provider to make improvements to the physical appearance of the service and although work had started, it had not been completed. There was no action plan or schedule of works to show how or when the improvements would be finished. A fire safety assessment had identified that the external fire escape was unsafe but this work had not been prioritised. The service smelt of cat urine. Professionals told us they had raised this with the registered manager before our inspection, but no action had been taken to improve the odour.

Staff did not know how to recognise and respond to abuse. Staff had documented that people had unexplained bruising and skin tears and although the registered manager told us they had, ‘checked these out’ there were no records of these checks. People were unable to confirm these checks had taken place, as they were living with dementia.

People told us that staff were kind and caring, but that they had to wait to receive support. Staff had not been deployed effectively and people were left waiting at lunchtime. They did not always receive the assistance they needed to eat effectively. There was a task led culture within the service. Staff were busy and did not have time to deliver person-centred care.

There were no dementia specific activities and people told us that they were bored. People who were unable to leave the service without staff assistance told us they missed going out and were not supported to go to church or practice their faith.

Staff had met with their line manager to discuss their practice and received some basic training. However, there was no training in topics specific to people’s needs such as epilepsy or skin care. There was a lack of guidance for staff on how to support people with their health care conditions and when to seek medical assistance. People were at risk of receiving inconsistent care.

The provider and registered manager did not have oversight of the service. They had sent us an action plan following our last inspection and this had not been adhered to. The provider did not carry out regular audits or checks to ensure the service was being run safely. The registered manager told us they had stopped checking and sampling people’s care plans because they, ‘knew they needed to be updated.’ People, their relatives and other stakeholders had not been asked their views on the service since our last inspection.

People’s relatives spoke positively about the care people received and said they were always made to feel welcome at the service. The registered manager greeted relatives warmly and everyone told us they were a visible presence within the service. There had been no complaints since our last inspection.

Medicines were now managed safely. There were appropriate arrangements in place for the ordering, storing, administering and disposal of all medicines.

The registered manager had notified us of important events that had happened within the service and staff were recruited safely.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there were any restrictions to their freedom and liberty, these had been agreed by the local authority as being required to protect the person from harm. The registered manager had applied for DoLS when necessary. People were supported to make day to day choices about their lives, such as what they ate and where they spent their time.

We found a number of breaches 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 the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still 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 this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

St Claire's Care Home provides care and support for up to 39 older people. There were 35 people living at the service at the time of our inspection. People cared for were all older people; most of whom were living with dementia and some who could show behaviours which may challenge others. People were living with a range of care needs. Some people needed support with all of their personal care and some with eating, drinking and their mobility needs. Other people were more independent and needed less support from staff.

St Claire's Care Home is a large house, previously arranged as three attached houses, now converted to a single property. People’s bedrooms were provided over four floors, with a passenger lift providing stair free access. There were communal sitting rooms and a communal dining area. There was an enclosed area of garden at the front of the property.

A registered manager was 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.

St Claire's Care Home was last inspected on 2 September 2014 and no concerns were identified. At this inspection we identified shortfalls where some regulations were not being met.

Medicines were not administered or stored safely; some people did not receive the medicine they were prescribed when needed.

There were insufficient staff at key times of the day; the registered manager often supplemented staff to provide support at busy times, this impacted upon the completion of management tasks.

No system was in place providing an oversight of incidents and accidents; reviews following an incident did not take place or link back to risk assessments and care planning.

The safety certificate for the electrical wiring of the service had expired, urgent remedial work had not been completed and checks of portable electrical appliances had lapsed.

Maintenance of the service was not adequate, some pipes were leaking, some furniture was no longer serviceable, a magnetic gate lock didn’t work and some areas required redecoration.

Records of staff recruitment and training were muddled and not readily accessible, induction training for new staff was not completed. Supervision of staff had lapsed and did not meet the requirement of the service’s policy.

Deprivation of Liberty Safeguarding authorisations had not been applied for where people were unable to consent to restrictions in place.

Elements of some care plans were not tailored to individual preferences and clear links were not always made between some conditions and other associated care needs. This did not provide the service with the best and earliest opportunity to be responsive to changes in people’s needs.

Auditing carried out for the purpose of identifying shortfalls in the quality and safety of the service provided had not been effective; deficiencies brought to the attention of the provider were not acted upon when needed.

People were supported by enthusiastic staff who received regular training and appropriate supervision. There were enough staff to meet people’s needs.

Staff were caring, compassionate and responsive to people’s needs and interactions between staff and people were warm, friendly and respectful.

Referrals to outside healthcare professionals were made in a timely way.

People enjoyed their meals, they were supported to eat when needed and risks of choking, malnutrition and dehydration had been adequately addressed.

People commented positively about the openness of the management structure and were complimentary of the staff.

We found a number of breaches 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 the report.

We looked at the answers to five questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

Is the service safe?

We viewed all communal areas of the home including lounges, dining-room, toilets and bathrooms; and viewed some of the bedrooms. We saw that the premises and the small garden area were satisfactorily maintained, and met the needs of the people who were living there. The building provided a safe environment, with gates to stairs, and keypad locks to doors to promote people's safety. This also helped to maintain people's independence.

The building was visibly clean in all areas, and we found that there were suitable cleaning programmes in place and management of infection control. Staff were informed about the use of personal protective clothing and colour-coding for cleaning equipment, and followed the directions accurately.

We talked with the manager about safeguarding people with dementia. We found that the manager and senior staff were informed about how to protect people from identified risks. We saw that general risk assessments for the home were in place, and individual risk assessments for each person.

The manager showed us that she understood her responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). An application for a Deprivation of Liberty Safeguard would be made for people who were assessed as needing their liberty restricted for their own safety. The manager told us that there were no current applications in place for DoLS. We saw that people's next of kin or authorised representatives were included in complex decision-making and consent procedures. This was so that they were involved in making decisions for people on their behalf and in their best interests.

Is the service effective?

The manager assessed people prior to their admission to ensure that the home would be able to meet their assessed needs. We saw that the assessments contained comprehensive information, enabling the manager to make an informed decision.

Care plans were reviewed and updated monthly, or more frequently if people's needs changed. Staff had daily handovers to keep them up to date with any changes. The staff involved people's relatives or representatives in care planning, and kept them informed of people's changing needs.

The home provided people with a suitable variety of foods which met their individual nutritional needs. We saw that drinks and snacks were offered throughout the day, as well as three main meals each day, mid-morning and mid-afternoon drinks with biscuits or cakes, and supper before bedtime.

We found that staff had been trained in required subjects such as health and safety, moving and handling, infection control and fire awareness. We saw that this training was kept up to date. Other relevant training courses were provided so that staff could develop their knowledge in line with people's individual needs, such as training in diabetes. Staff said that they felt supported by the manager and could talk with her at any time.

Is the service caring?

We observed that staff treated people with respect and dignity at all times, and had a gentle caring manner. They did not rush people, and did not try to make them do things that they did not want to do. This showed that they were aware of people's individual moods, and knew how to care for them effectively. People that we spoke to expressed their satisfaction with the staff team, with comments such as, 'They are very good girls', 'They are all lovely', and, "They are very kind."

We saw that people were able to go to the lounges, the dining-room or their own rooms as they liked. Some people liked to wander along the corridors. The staff were familiar with people's likes and dislikes, such as giving them books or magazines to read, or singing along to music with them. Two people had their own cats with them and were very pleased about this. A range of group activities were provided in the afternoons for people who wanted to join in with these.

Is the service responsive?

The home had local GP practices nearby, and most people chose to be registered with a practice where a doctor visited the home at least once per week. This enabled people to see a doctor as needed. The manager said that they had a good liaison with the community services, and this included regular visits from community nurses and other health professionals.

The manager ensured that people's personal wishes were respected and followed. We met two solicitors who were visiting a person in the home, and who acted on their behalf. Another person's relative told us, 'The staff always let me know what is going on, or contact me if there are any concerns. If I had any worries I would come and see the manager. I know she would sort things out.'

We saw that the complaints procedure was on display in the entrance hall, so that it was easily available to people visiting the home.

Is the service well-led?

We saw that the manager had a visible presence in the home, and was well-known by the people who lived in the home, and the staff and relatives. She had an open door policy, and was always available to talk to people if they had any worries or concerns.

Staff said that they had daily handovers, and changes were discussed during these times. The manager carried out individual supervision with staff every two to three months; and yearly appraisals were completed. This provided staff with the opportunities to discuss individual training needs, and to develop within their different roles.

We found that there were auditing systems in place to monitor the management of the home. This included different weekly and monthly checks for equipment, risk assessments, care plans, medicines, and accidents or incidents. This provided an on-going monitoring system to assess how the home was running.

Our inspection of 15 November 2013 found inappropriate arrangements for the storage of controlled drugs and no recorded staff guidance for the administration of 'when required' and 'homely remedy' medication. At this inspection we found that people were protected against the risks associated with medicines because the provider had made improvements to the management of medicines within the service.

Our inspection of 15 November 2013 found that staff recruitment checks undertaken before staff began to work at the service were not sufficiently robust. At this inspection we found that a staff recruitment checklist was used to make sure that all the appropriate checks were undertaken and recorded. This meant that there were effective recruitment and selection processes in place that made sure that people who used the service were fully protected.

People's needs were assessed before and when they first started to use the service. During our inspection, we saw that for two people no care plans or risk assessments had been developed to give staff detailed guidance about how to meet their needs and how to keep them safe.

People were not protected against all the risks associated with medicines because the provider did not evidence appropriate arrangements for the storage of controlled drugs and staff guidance for the administration of 'when required' and homely remedy medication.

People benefitted from comfortable accommodation. Each person who used the service had their own bedroom. We saw that people were supported to personalise their bedrooms according to their individual preference. People who used the service, staff and visitors were protected against the risk of unsafe premises.

The provider did not fully evidence that recruitment procedures were sufficiently robust to ensure that people were cared for by suitably qualified, skilled and experienced staff.

People who used the service and their relatives and representatives were asked for their views about the service provided. We saw that people were able to communicate their wishes to staff, who listened and took action.