St Thomas

St Thomas is a nursing home providing personal and nursing care for to up to 72 older people, some of whom may be living with dementia. The service is provided in one adapted building across two floors. There are ensuite bedrooms across the ground and first floors, with shared living areas and access to a garden on the ground floor. At the time of our inspection there were 57 people using the service.

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

People and their relatives told us they felt safe at St Thomas. Risks to people’s health, safety and wellbeing had been assessed and measures were in place to manage these risks. Medicines were managed safely. We identified some areas where recording could be improved, and immediate action was taken. Incidents and concerns were reported and investigated appropriately, and actions taken in response. There were enough staff to support people safely on our inspection.

People had access to health services to meet their needs, and there was positive feedback from healthcare professionals about their relationship with the home. People had enough to eat and drink, they had choices and were supported with foods which met their needs. The staff team were skilled in supporting people, including people with dementia or communication needs, however at times staff were rushed.

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.

The home had a change in management team since the last inspection, and there was a positive, open and inclusive atmosphere. Staff fed back that they were encouraged to be proactive and that the senior staff and managers were good role models. There was a robust quality assurance process in place, which had identified themes and areas for improvement identified on this inspection. The registered manager had a credible strategy and clear plan for continuing and embedding improvements.

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 6 May 2020)

Why we inspected

This inspection was prompted by a review of the information we held about this service and to review whether the service had made the required improvements since the last inspection. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 requires improvement to good based on the findings of this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

St Thomas is a nursing home providing personal and nursing care to up to 72 people who have a range of needs, including diabetes, restricted or limited mobility, end of life care and mental health and people living with dementia. At the time of the inspection 60 people were using the service.

The home is a large two-story building. The ground floor comprised of people’s bedrooms and communal spaces such as lounges, dining areas, and a hairdresser and barber area which were all centred around an internal courtyard. There was also a chapel situated off the main entrance to the home. The upper floor of the home primarily accommodated people’s bedrooms and there was a lift between the two floors, which people could use to access the communal areas on the ground floor. Both floors offered communal bathrooms and toilets and all bedrooms offered en-suite facilities of either a bath or shower.

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

There were appropriate numbers of staff deployed to meet people’s needs. However, we received a high volume of feedback from relatives, professionals and some staff that staff were not always accessible or visible, particularly in communal areas of the home. Staff worked hard, however some staff felt they were not always able to respond to people’s needs at the time they requested it. People were supported to receive their medicines, however some aspects of medicines management required improvement to ensure people were consistently supported in-line with the prescriber’s guidance. There were clear safeguarding systems in place and people were protected from the risk of harm. Risks to people were identified, and there was guidance for staff to follow to keep people safe.

The home accommodated a large proportion of people living with varying stages of dementia. The environment was not always conducive to meeting their needs and national guidance to support people living with dementia had not been consistently incorporated. For example, there was a lack of accessible signage and use of colour to support people’s orientation. People’s care plans included a range of monitoring tools and best practice guidance; however, we could not be assured peoples oral hygiene was always managed in-line with best practice guidance.

Where people were assessed as lacking capacity to make specific decisions, staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Systems and processes in place to monitor and improve service delivery were not always effective. The provider used a range of tools and audits to monitor the care people received, however they had not identified the issues we found at this inspection. There was a clear leadership team in place and staff knew where they could access advice and support. The registered manager was passionate about people’s outcomes and knew people’s needs well, however we received mixed professional feedback that the service consistently well-led.

People and their relatives told us staff were kind and caring. We observed staff treated people with respect and dignity and offered people choices throughout their day to day routines. People were supported by staff who knew them and their needs well. Staff understood the importance of maintaining people’s independence.

People had opportunities to engage in a range of activities. People were supported by dedicated activities staff to engage in meaningful activities based on their interests. People’s care plans were person centred, and captured people’s likes, dislikes and preferences. There was a clear complaints procedure in place and relatives told us they felt comfortable raising concerns with the leadership team.

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 good (published 09 August 2017).

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 Thomas (to be referred to as the home throughout this report) is a nursing home which provides nursing and residential care for up to 72 people who have a range of needs, including those living with epilepsy, diabetes, cancer, sensory conditions such as hearing and slight loss as well as people receiving end of life care. The home provides specialist support to those living with dementia. At the time of the inspection 59 people were using the service.

The home comprises a large two storey building which is set around a central courtyard and garden area which offers seating and shaded areas for people, relatives, visitors and staff to enjoy. It also provides areas of interest such as a pond with ornate metalwork to keep the pond safely enclosed and planting areas with flowers and trees for people to cultivate and enjoy. On the ground floor the home has living accommodation with communal areas including lounges and dining rooms. The ground floor is linked by adjoining corridors which are open to allow people to move freely around the home and the courtyard is accessible to all. The first floor comprises of living accommodation and a hairdresser and barbers area. The first floor is accessible by a lift allowing people access. 69 bedrooms have ensuite toilet and handwashing facilities and three rooms have ensuite shower rooms. Communal bathrooms and accessible toilets are available on both floors. On the ground floor a chapel provided people with the means to meet their spiritual needs and a linked coffee shop area enabled the chapel to also be used as a meeting point for people and their visitors.

The home 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 current general manager had been employed at the home in May 2017 and was in the process of becoming registered with the CQC.

People using the service told us they felt safe. Staff understood and followed guidance to enable them to recognise and address any safeguarding concerns about people. People's safety was promoted because risks that may cause them harm had been identified and guidance provided to staff to help manage these appropriately.

People were supported by sufficient numbers of staff to meet their needs. The provider was able to adapt their staffing levels appropriately when required in order to meet changes in people’s needs.

Recruitment procedures were fully completed to ensure people were protected from the employment of unsuitable staff.

People received their medicines safely; nurses were responsible for managing medicines and had received the appropriate training to enable them to complete their role safely. Medicines were stored, administered, disposed of and documented appropriately.

Contingency plans were in place to ensure the safe delivery of people's care in the event of adverse situations such as a fire or flood which may result in the loss of living accommodation. These were accessible to staff and emergency personnel such as the fire service, if required to ensure people received continuity of care in the event of an on-going adverse situation which meant the home was uninhabitable.

People were supported by staff who received appropriate training enabling them to meet people’s individual needs. Staff received regular supervision to ensure they were supported in their role.

People, where possible, were supported by staff to make their own decisions. Staff were able to demonstrate that they complied with the requirements of the Mental Capacity Act 2005 when supporting people. Records clearly documented that where people lacked the capacity to make specific decisions for themselves that actions taken on their behalf were always in their best interests. Staff sought people's consent before delivering their care and support.

People were supported to eat and drink safely whilst maintaining their dignity and independence. We saw that people were able to choose their meals and were offered alternative meal choices where required. People's food and drink preferences were documented in their care plans and were understood by staff. People were supported to eat and drink enough to maintain a balanced diet.

People’s health needs were met as the staff and manager promptly engaged with other healthcare agencies and professionals to ensure people’s identified health care needs were met and to maintain people’s safety and welfare.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which apply to care homes. The manager showed an understanding of what constituted a deprivation of a person's liberty by the correct submission of relevant applications to ensure people were not deprived of their liberty without legal authority.

People told us that care was delivered by kind and caring staff who sought to meet their needs and ensure they were happy. We saw that people had friendly and relaxed relationships with staff who would stop and speak with them as they moved around the home.

Care plans and risk assessments contained detailed information to assist staff to provide care in a manner that respected each person's individual requirements and promoted their dignity. People were encouraged and supported by staff to make choices about their care including how they spent their day in the home.

People’s care plans and risk assessments were reviewed monthly or sooner when required to ensure they remained accurate to enable staff to effectively meet people’s needs.

People living with specific health conditions such as epilepsy for example were supported to manage these conditions safely. Guidance regarding the management and monitoring of people’s blood glucose levels was available and we saw this guidance was followed in practice.

People knew how to complain and told us they would do so if required. Procedures were in place for the manager to monitor, investigate and respond to complaints in an effective way. People, relatives and staff were encouraged to provide feedback on the quality of the service during regular meetings with staff and the manager.

The provider’s values were communicated to staff. Staff understood these and relatives told us these standards were evidenced in the way care was delivered.

The manager and staff promoted a culture which focused on providing care to people in the way that staff would wish their family members to receive. The manager provided strong positive leadership and fulfilled the requirements which would be associated with their role as a manager.

The manager had informed the CQC of notifiable incidents which occurred at the service allowing the CQC to monitor that appropriate action was taken to keep people safe. Quality assurance processes were in place to ensure that people, staff and relatives could provide feedback on the quality of the service provided. People were assisted by staff who were encouraged to raise concerns with the manager.

The quality of the service provided was reviewed regularly by means of effective quality control audits. These were completed to identify areas where the quality of the service provided could be improved. We could see action had been taken to address where any shortfalls in the service provision had been identified.

A registered manager was in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service is required by a condition of its registration to have a registered manager.

The provider had a staff dependency tool in place, however we could not be assured that there were always sufficient staff deployed to safely meet the needs of the people living at the home. The registered manager had made some environmental changes to enable people to have more freedom to move around the home. This had been well received by staff and relatives. However, some further evaluation was required to ensure that staff were always effectively deployed to support people to make the most of this freedom, by ensuring that they were safe, had opportunities for social interaction and that their care needs were met.

The registered manager had made other changes during the past year to develop and improve the service. Some of these changes needed time to bed in to ensure they could be sustained, for example the post falls protocol which had recently been introduced.

Staff told us that there was an open culture at the home and they felt able to talk to the management team about any concerns. Processes were in place to enable people and relatives to provide feedback to the registered manager through residents and relatives meetings. However not all relatives felt they had been listened to if they raised concerns.

Staff did not always demonstrate an understanding of how to deliver good care to people living with dementia. While they were kind and caring towards people when they did interact with them, they sometimes missed opportunities to engage with people and ensure that they were getting the social interaction and stimulation they needed. There was also a lack of activities provision at the time of the inspection. The registered manager was in the process of recruiting a new activities co-ordinator and assistant. The provider had recognised the need to improve the experiences of people living with dementia and was undertaking work around this.

Risks to people's safety had been identified, managed and reviewed. These included potential hazards in the environment and risks when people were supported by staff to move or transfer. They also included an assessment of the risk to people of falls, weight loss, choking and the development of pressure sores. Staff knew what action they needed to take to manage risks and keep people safe.

People were supported by staff who had been trained in safeguarding and were able to recognise the signs of abuse. Safeguarding policies and procedures were in place and staff knew what to do if they had any concerns.

Recruitment procedures were in place to ensure that people were protected from the risk of employment of unsuitable staff. New staff followed a period of induction to ensure that they had the necessary skills and confidence to fulfil their role.

People were protected from the unsafe administration of medicines as there were clear processes and procedures in place for the safe receipt, storage, administration and disposal of medicines which nurses followed.

The provider had a programme of mandatory training to ensure that people had sufficient skills and understanding to meet people’s needs effectively. There was a system in place to ensure that training was regularly refreshed. There was a programme of supervisions and appraisals and staff told us that they felt supported by their team leaders and managers.

Where possible, people were supported to make decisions about their care and treatment. Where people did not have the capacity to consent, the provider acted in accordance with the Mental Capacity Act 2005. This meant that people’s mental capacity was assessed and decisions were made in their best interest involving relevant people. The registered manager was aware of her responsibilities under the Deprivation of Liberty Safeguards (DoLS) and had made appropriate applications to the local authority. Records confirmed that appropriate procedures had been followed to ensure that decisions about people’s care had been made in their best interests and in accordance with good practice.

People were supported to have enough to eat and drink to meet their nutritional and hydration needs. People received support to eat in accordance with their care plans. People were offered choice at mealtimes and drinks and snacks were available. The registered manager had made changes to the dining arrangements to improve people’s mealtime experiences.

During the inspection we saw people being spoken to with warmth and kindness when they were being supported by staff. People’s independence was promoted, particularly following the recent changes to the environment which meant that people were less restricted in gaining access to different parts of the home. We observed people being offered choice in their daily routines and asked for their views. People told us that staff treated them with respect and dignity and that they had the privacy they needed.

People’s care and support needs were documented and regularly reviewed. People were able to gain access to healthcare services to meet their health needs.

The provider had systems in place to manage complaints and concerns. Records showed that formal complaints had been responded to in accordance with the provider’s complaints policy.

Audits carried out by the managers at the home had been effective in identifying improvements and action plans had been put in place and completed.

The registered manager led by example and set high expectations for staff to ensure there was a continuous improvement in the delivery of care.

This service is currently registered with the CQC to provide the regulated activities of accommodation for persons who require nursing or personal care, treatment of disease, disorder or injury, and diagnostic or screening procedures. However, the regulated activity of diagnostic or screening procedures was not being provided at the time of our inspection.

Information of concern had been brought to our attention regarding people's care and staff training. We considered these concerns as part of our inspection. We observed how staff supported people, and looked at documents including care plans and management reports. We considered all the evidence we gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; is the service caring, responsive, safe, effective and well led?

This is a summary of what we found.

Is the service caring?

The service was caring. We observed that staff treated people with kindness and patience. Relatives told us that staff were caring. One relative told us their loved one was 'Perfectly happy and has settled in well'. We observed staff engaged people in conversation, and explained actions such as hoisting before starting the task to provide reassurance.

Is the service responsive?

The service was responsive to identified issues. For example, we observed prompt action to support a person who had a fall during our inspection, and to adjust another person's clothing when it put them at risk of falling. One relative told us that staff 'Dealt with incidents quickly. They listen to our comments'.

People's care records reflected people's current needs. We saw evidence of care plan and risk assessment updates documented in response to changes in people's needs.

Is the service safe?

Some areas of the service were safe. Safeguarding concerns had been reported and dealt with appropriately. Deprivation of Liberty Safeguards (DoLS) applications had been appropriately submitted to ensure that where people's freedom had been restricted, this was in accordance with the law to protect them from identified risks.

The service did not have systems in place to promote good hygiene and infection control. We found clinical waste had not been safely secured, and cleaning schedules did not document that required cleaning had been completed. A relative told us visitors had to be careful where they sat because the chairs were often wet.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to infection control.

Although staffing numbers met the provider's required number, we observed that people were not always well supported. For example, some people experienced a long delay for their lunch, and staff were not always available to monitor communal areas when required.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing.

Is the service effective?

The service did not always operate effectively. Care staff told us they did not feel equipped to deal effectively with people's behaviours when they were more challenging Training records demonstrated that essential training had not always been refreshed in accordance with the provider's policy. Staff had not received regular one to one supervision meetings or annual appraisals to discuss concerns, issues or aspirations.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting staff.

Risk assessments had identified areas where people's health and wellbeing may be affected, for example through conditions that made them susceptible to developing pressure sores. People with behaviours that may challenge their own or others wellbeing had been identified. However, we saw that people had still developed pressure sores. When people presented with more challenging behaviours, staff had not received detailed guidance or training to manage these appropriately.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people's care provision promotes their care and welfare.

Is the service well led?

We found the service was well led. A relative told us 'The manager is spot on and knows what they are doing'. Quality audits had been used to identify elements requiring improvement, and action plans demonstrated that improvements had been made. Relatives told us they had the opportunity to raise and share concerns through meetings, although not all felt their comments were listened to. We observed relatives were welcomed into the registered manager's office to discuss people's care, and to raise concerns as necessary.

Care and treatment was well planned but staff did not always follow the guidance. People's needs had been assessed. However because staff did not always follow the guidance these needs were not always met.

People were able to have food and drink when they wanted it. Drinks were left in people's reach and adapted cups were used so that people could drink independently. We observed that the food looked appetising and people's nutritional needs had been considered. Staff ensured that people unable to feed themselves were given full assistance and their diet was closely monitored.

Staff were supported by management and offered appropriate professional development. All staff we spoke with recognised that recent staff changes had presented a challenge but most felt things were heading in the right direction.

There was process in place to identify and monitor the risks to the health, safety and welfare.

During our visit of 13th June 2012 we found that improvements were required to provide adequate nutritional support. Improvements were also required for the appropriate storage and safe handling of medicines. On our visit we saw that improvements had been made in both these outcome areas.