St Mungo's Broadway - 2 Hilldrop Road

We found the following examples of good practice.

When people had COVID-19 symptoms, they were asked to take a COVID-19 test and to self-isolate until the result was received. These people were allocated their own bathroom and a sign was placed on their bedroom door stating when their self-isolation period was ending. This simple signage reassured people. It reminded those who were self-isolating and others in the service when they would be able to socialise with their peers again. This increased compliance with social distancing and self-isolation rules.

The service formed social bubbles when people struggled to social isolate. In one case, a group of people using the service, because they were in close contact with the same person with suspected COVID-19, had been allocated a designated area at the service (bedrooms, bathrooms and communal areas) where they were spending time while self-isolating. Staff were allocated to support the bubble with food, fluids and other needs people might have. Although the people involved still needed to observe social distancing rules, they responded well to it. This increased their collaboration with the COVID-19 infection control measures and the risk of spreading of infection was reduced.

The service allowed visits from friends and families throughout the pandemic. This took place outside of the building. People using the service had capacity and could go in and out of the service when they wanted. However, due to their physical and mental wellbeing (for example long and short-term memory loss), they did not always follow the national guidance. Allowing people to receive visitors outside the building helped monitoring and reduction of people’s social contacts and reduction in risk of containing and spreading the coronavirus.

St Mungo's Broadway – 2 Hilldrop Road is a care home which is registered to accommodate a maximum of 29 people with a history of alcohol misuse, homelessness and mental health conditions. On the days of our inspection, the service was providing care for 23 men.

During this inspection we found that the service had been steadily improving and addressing all issues identified by us during our inspections in December 2016 and May 2017. Staff and people using the service commented positively about the changes within the service. Both staff and people were encouraged to share their opinions, by the provider, about the service and contribute to any developments in the service provision.

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 current registered manager had joined the service in December 2017. The registered manager was supported by the members of the providers management team including the regional director and the head of services as well as the newly appointed deputy manager. The management team had the training and experience necessary to manage the regulated activity of accommodation for persons who require nursing or personal care.

At this inspection we found that the service had made improvements to how they managed medicines and people received their medicines in a safe way. Some additional improvements were needed to ensure PRN (as required) medicines administration was recorded correctly at all times and that PRN stock levels reflected the needs of people who used the service.

Risk to health and safety of people had been assessed and people lived in a safe environment. The provider needed to ensure all risk assessments carried out were equally robust and that appropriate records were in place to help to keep people and staff safe at all times.

The service provided people with freshly prepared food and drink which was nutritional and in suitable amounts. Staff were in the process of creating a nutrition information folder to ensure kitchen and care staff had an easy access to this information.

The provision of social activities at the service was reduced due to the recent changes in staff structure. However, the service was in the process of reviewing how activities were provided to ensure there was sufficient amount of interesting and fun things to do for people who used the service.

Staff helped to protect people from avoidable harm from others. Staff were trained in safeguarding adults and they understood their role in ensuring people using the service were safe from any type of abuse. Robust recruitment procedures in place ensured that only suitable staff worked with people. There were enough staff deployed on each shift and people’s needs were met with no delay.

The registered manager had assessed needs and preferences of people who used the service before they moved in. People were able to visit the service during the assessment process to find out if they liked it and if they would like to live there.

Staff were provided with regular mandatory and specialist training to enhance their skills and to be able to provide safe and effective care to people. Staff were also supported and their performance was monitored in regular one to one supervisions and yearly appraisal of their skills.

The service worked within the principles of The Mental Capacity act 2015 (MCA). Best Interest Decisions had been made when people did not have the capacity to decide about their care and treatment. Staff asked for people’s consent before providing any care.

Staff supported people to maintain a healthy lifestyle and had access to appropriate health and social professionals when required.

People were supported by kind and caring staff who respected people’s individual ways of being. Each person had an allocated key-worker who coordinated their care and supported people in making decisions about the support they received from the service.

Staff respected people’s privacy and dignity at all times. People were free to spend their time as they liked and staff did not interfere. However, staff always checked that people were well and safe.

Each person using the service had a person centred care plan which provided staff with information about who people were, what were their care needs and what goals they wanted to achieve through support received from the service. Staff took their time to learn and understand what people’s needs were and what was important to them.

The service promoted equality and diversity amongst people using the service and the staff team. Religious needs had been respected and different cultures were celebrated.

The service had dealt with people’s complaints promptly and according to the provider’s policy.

Staff told us they were supported by the management team. Staff were encouraged to use their skills, knowledge and personal interests to contribute to the improvement in the service delivery.

People were encouraged to express their views about the service they received. Evidence, such as records and our discussions with people who used the service, showed that people were asked about their preferences in how they would like the service to be provided and we saw that people’s opinion mattered.

There were sufficient quality monitoring systems in place to ensure continuous good quality of the service delivery.

We made one recommendation about management of PRN (as prescribed) medicines.

At our last inspection on 14 and 15 November 2016, we found significant shortfalls in the care provided to people. We identified breaches of Regulations 9, 10, 11, 12, 14, 15, 17, 18 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition, we identified breaches of Regulations 16 and 18 the Care Quality Commission (Registration) Regulations 2009.

These breaches related to inadequate care planning and risk assessment, poor infection control practices, unclean, poorly maintained and unsafe premises, unsafe recruitment practices, inadequate provision of staff training, supervisions and appraisals, poor staff understanding of the Mental Capacity Act (MCA), lack of provision of drinking water and a lack of auditing processes to ensure good governance and overall management of the service provided. We were not satisfied that care and treatment was being provided safely.

We took action to impose a condition which required the provider to undertake a monthly audit of care plans, risk assessments, cleaning and maintenance, infection prevention and control, staff training, supervisions and appraisals, staff recruitment, incident reporting, staffing levels and submit a monthly report to the Care Quality Commission (CQC) outlining their findings.

The provider was also placed into special measures. Special measures are designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Its purpose is to ensure that inadequate care significantly improves and provides a clear timeframe within which the provider must improve the quality of care they provide. When a provider is placed into special measures, the CQC will re-inspect within six months.

This inspection was carried out within the six-month time frame to check if improvements to the quality of care had been implemented. At this comprehensive inspection we found the registered provider had taken action to achieve compliance with all of the regulations previously identified as non-compliant during the comprehensive inspection in November 2016. However, we identified concerns regarding medicines management.

At the time of the inspection, the registered manager was no longer working at the service. An interim manager was responsible for day to day running of the service. The regional director advised us that they were commencing recruitment for a new registered manager. 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.

Medicines were not being managed safely. People's Medicine Administration Records (MAR's) were not always completed in full or accurately. We found one instance of a medicine not administered as prescribed. Medicines stocks were not checked. Medicine audits had failed to identify and improve on the issues that we found.

At this inspection, we found that levels of cleanliness had significantly improved across all areas of the service. Infection prevention and control measures were in place and monitored. Hand washing facilities were available in toilets and bathrooms.

Staffing levels and deployment had been reassessed and increased. Additional dedicated cleaning staff were recruited and an additional staff member was deployed to support senior staff.

Incidents and accidents were recorded and reported to appropriate external organisations.

At this inspection, we found detailed current risk assessments were in place for people using the service. Risk assessments explained the signs to look for when assessing the situation and the least restrictive ways of mitigating the risk based on the individual needs of the person. However, we identified two instances of where risk assessments had not reflected the person’s current circumstances, which was brought to the attention of the provider and addressed.

We found that care plans were person centred and reflected what was important to the person. Care plans provided appropriate guidance to enable staff to deliver person centred care in line with people's preferences.

Staff training, supervisions and appraisals were monitored and updated regularly. Systems had been implemented to ensure a better oversight of when staff training, supervisions and appraisals were due.

Staff were safely recruited with necessary pre-employment checks carried out.

Significant improvements had been made to ensure that consent to care was obtained from the appropriate person. Care plans specified best interest decisions that had been made. All staff had received training on Mental Capacity Act 2005 (MCA) and staff understood the importance of obtaining consent from people.

People had access to drinking water and a tea room had been created to enable people to make their own hot drinks at a time of their preference.

People told us they were treated with dignity and respect and that staff were caring. We received consistent feedback from staff that as a result of staffing changes, they were able to spend more time and develop better relationships with people who used the service.

The provision of activities had increased and care staff were enabled to deliver activities in evenings and weekends.

Referrals had been made to other healthcare professionals to ensure people's health was maintained.

Staff and resident meetings were held regularly.

We found that improved systems were in place to monitor and check the quality of care provided. We received consistently positive feedback from staff regarding the management structure in place and the support they received. Managerial oversight of the service had improved since the last inspection. Good practice had been developed, but further time was needed to address outstanding issues and for the service to demonstrate that the improvements that had already been made had been fully embedded and could be sustained.

At this inspection, we identified a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However, as the provider has demonstrated significant improvements, the service is no longer rated as inadequate for any of the five questions and it no longer remains in special measures.

St Mungo’s Broadway – 2 Hilldrop Road is a care home which is registered to accommodate a maximum of 29 people with a history of alcohol misuse, homelessness and mental health conditions. On the days of our inspection, the service was providing care for 27 men.

The home had a registered manager. 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 home was unclean. The premises and equipment within the home was not maintained. Infection control was not being followed as adequate hand washing facilities were not always available and staff did not have access to sufficient personal protective equipment (PPE) and cleaning materials.

The provider did not adequately assess risks for all people using the service. Identified risks had not been assessed for all people who used the service. Risk assessments did not provide staff with enough guidance on how to recognise risk, actions to take or how to mitigate identified risks.

There were not always enough staff deployed in the service to consistently meet people's needs. People were left on their own for long periods of time without the support of staff. Not all of the care staff on duty provided care to people. Some staff were seen to be undertaking cleaning tasks only.

Incidents and accidents were not always recorded and reported to appropriate external organisations.

The provider did not always adhere to the Mental Capacity Act 2005 (MCA). The provider did not have a MCA or Deprivation of Liberty Safeguard (DoLS) policy in place. There were no best interest decisions or mental capacity assessments highlighting that people did not have capacity to sign their care plan or forms consenting to their care. Not all staff had received training in the MCA and staff did not always understand how this legislation impacted on the lives of people they were working with.

People were not always receiving care from staff who were competent, skilled and experienced. There was a risk that people were receiving care from staff who had not received training to meet the needs of people with certain health conditions. The provider did not keep appropriate records of training, identify staff training needs or monitor when staff needed their training updated.

Not all staff had appropriate regular supervision or annual appraisals.

People did not have access to drinking water and had to ask staff for drinks which sometimes resulted in a lengthy wait and placed people at risk of dehydration.

People’s privacy and dignity was not always respected.

Care plans were not person centred and did not state people’s individual preferences. Most care plans had not been signed. Updated care plans were contained electronically which meant that not all staff had access to the most up to date version as some staff did not have access to the electronic care management system. Care plans were not updated to reflect people’s changing health needs and important medical information was missing.

The provider did not always ensure robust recruitment practices were in place. Not all staff had a criminal records check carried out before working with people.

There were not effective systems in place to assess and monitor the quality of the service. Although some quality checking had been undertaken these had not been used to improve the quality of care for people. Records were not always completed or accurate. Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The provider had not informed CQC of all significant events in this regard.

There was an activities programme which was well received by people who used the service. However, at times we observed people sitting for long periods of time watching television without any meaningful engagement from staff.

Referrals had been made to other healthcare professionals to ensure people's health was maintained.

Staff and resident meetings were held regularly.

Medicines were managed safely and effectively.

Overall, we found significant shortfalls in the care provided to people. We identified nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and two breaches of Care Quality Commission (Registration) Regulations 2009. As a result, we imposed conditions on the providers registration on 4 January 2017 requiring the provider complete a monthly audit of the service focusing on cleaning and maintenance, infection prevention and control, health and safety checks of the premises, staffing levels and deployment of care staff, staff training, supervisions and annual appraisals, incident reporting and staff recruitment. We also imposed a condition on the provider to submit a monthly report to the Care Quality Commission outlining the outcomes of the monthly audit and any actions taken or planned to be taken as a result.

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 and if 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.

On 1 May 2014 we visited and found that essential standards relating to management of medicines, and safety and suitability of the premises, were not being met. The provider submitted an action plan detailing how they would meet these standards. During this visit, on 10 September 2014, we checked whether the provider had carried out the actions and whether the standards were now met.

We found that medicines were managed appropriately and safely, and that people received the medicines they needed. Medicines were stored according to the manufacturers' instructions, and this was checked regularly by the provider.

We found that the premises were appropriately maintained, and had undergone a deep clean since our last visit to ensure that people were protected.

The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Suitable risk assessments had been carried out and staff were knowledgeable about the content of these.

Members of staff had been through an appropriate recruitment process to ensure that they had the skills and experience needed to safely support the people living at this service.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. None of the people who used this service had applications submitted under this system. However, we saw evidence that the manager was organising training for staff in relation to the operation of the DoLS.

We noted some problems with the maintenance of the premises. In some cases this meant that people may not have been safe, or may not have had their privacy protected, when they were on the premises. We also found that people were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. We have asked the provider to draw up an action plan in relation to these risks and we will go back to the service to check that these actions are implemented.

Is the service effective?

We found that people's needs had been assessed and suitable support plans were in place. These were regularly reviewed. There were systems in place for obtaining verbal and written consent prior to providing support. The service used a system called 'Outcome Stars' as a method for involving people in decisions about their care.

People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others.

Is it caring?

We observed that people were mostly relaxed and confident in their interactions with staff. Staff responded calmly when people became agitated. We spoke with five people using the service. Most people were satisfied with the support that they received. One person said "It's all right here." Someone else told us "The support is ok and they are aware of my health problems." However, there were some people who told us they were not happy with the service. For example, one person said "I don't like it here. I am lonely and no one cares."

Is the service responsive?

We examined how the service responded to verbal and written complaints as well as what actions they took in response to any adverse incidents involving people who used the service. We saw that the service had not received any written complaints. More general concerns were raised by people at monthly residents' meetings. These were monitored and responded to. The service could also show us evidence of how they responded to incidents. We saw that steps were taken to minimise the possibility of any incident recurring.

Is the service well-led?

The provider had effective systems to regularly assess and monitor the quality of service that people received. Various health and safety audits were carried out including weekly fire and daily room safety checks. We saw that the service was making appropriate notifications to regulatory bodies, such as the CQC, in relation to any incidents or adverse events that had occurred.

People using the service were invited to attend monthly residents' meetings to feedback information about the quality of the service to the managers. Members of staff met daily for an hour long handover meeting where they discussed issues relating to the people using the service and their support needs. Members of staff were also currently attending reflective practice sessions which the provider had arranged for them. The members of staff that we spoke with told us that they found these sessions beneficial.

We found that each of the measures in the provider's action plan had been implemented. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

People's preferences were considered in relation to the delivery of care and people were involved in care planning. The provider respected people's choices and considered people's cultural needs.

We found that people's needs were assessed and that risk assessments and care plan records were reviewed as necessary.

The provider made sure that people who used the service were involved in deciding the food menus and that people were given a choice at each mealtime.

We found that people were protected from the risks of abuse as the provider took steps to make sure that people were protected. Staff we spoke with demonstrated that they knew their responsibilities to make sure people were protected.

Staff showed they knew the needs of the people they provided care to and staff we spoke with told us that they felt supported by the provider. We found that staff were supported to identify training needs and to attend relevant training.

We found that people were at risk of inappropriate care as the provider did not effectively record appropriate information in relation to the management of the service and the delivery of care.

The provider had effective systems in place to monitor care quality.