Archived: St Johns Wood Care Centre

St Johns Wood Care Centre is a care home providing personal and nursing care to 80 people aged 65 and over at the time of the inspection. The home can support up to 100 people.

The service provides nursing and personal care on five floors. People have their own ensuite bedrooms and share bathrooms and shower rooms, as well as lounges and dining rooms on the floor where they live.

One floor specialises in caring for people with dementia, however, people living with dementia also live on other floors of the home. Another floor specialises in caring for people with acquired brain injury.

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

People were not always protected from potential harm as risks were not managed effectively and staff were not always provided with up to date guidance about how to prevent harm. Medicines management was not given the necessary oversight by management of the home. The use of insulin was not monitored appropriately and had not identified emerging issues about incorrect insulin doses. Although no one was identified as having suffered direct avoidable harm the potential that some may do so was not mitigated as thoroughly as it should be.

Care planning was complex and confusing, and the way information was gathered and updated was not readily accessible. The nursing and care staff we spoke with, in almost all conversations, knew people they cared for well. Updating the current assessment of need for each person using the service had begun prior to this inspection, however, this remained an unresolved issue that was identified at the previous inspection that had not been fully addressed.

People were not always supported to have maximum choice and control of their lives. Although staff usually supported people in the least restrictive way possible and in their best interests; the policies and systems in the home did not effectively support this practice. Consent, if not obtainable from some people using the service, was not obtained from those with the authority to consent on people’s behalf in some cases.

Most people and relatives we spoke with felt able to raise things they wanted to with management or other staff at the home. People usually felt that staff were caring. We observed some caring interactions, although we also observed some occasions where the way staff interacted and spoke with people was not as caring and respectful as it should be especially during mealtimes.

The provider’s oversight and management processes, although in recent months highlighting some issues to be addressed, had not resulted in timely action to achieve the improvement necessary.

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

Rating at last inspection and update

The last rating for this service was Requires Improvement (report published 16 October 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvement had not been made and the provider was still in breach of regulations.

The home is now rated as inadequate.

Why we inspected

The inspection was prompted in part due to concerns received about fire safety and infection control. A decision was made by CQC to inspect earlier than had originally been scheduled to examine these concerns. We also checked progress regarding the previous breaches of regulations 9 (Person centred care) and 12 (Safe care and treatment).

We have found evidence that the provider has deteriorated in the day to day management of the service and needs to make improvement. Please see the Safe, Effective, Caring, Responsive and Well-led sections of this full report.

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

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

Enforcement

We have identified ongoing breaches in relation to Regulation 9 (Person Centred Care) and Regulation 12 (Safe care and treatment). Risk assessment processes and care planning were each identified as ongoing breaches. Safe management of medicines was additionally identified as requiring action to ensure the safety of people using the service at this inspection. We issued a warning notice in respect of Regulation 12 to be complied with by no later than 12 July 2019 and Regulation 9 to be complied with by no later than 9 August 2019.

We also identified breaches to other regulations as follows. Regulation 10 (Dignity and respect) as some engagement with people was not respectful. Regulation 11 (Consent) as consent to care and treatment was not obtained for some people. Regulation 17 (Good governance) as there were widespread and significant shortfalls in service leadership and the culture created did not assure the delivery of high-quality care. Regulation 18 (Staffing) as staff were not being supported though supervision.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

This inspection took place on 25 and 26 July 2018 and was unannounced. This is the first inspection of the home since the provider, MMCG (2) Limited, took over as the provider of the service in July 2017. We found that the provider had implemented oversight systems for monitoring of the performance of the service. These processes had not, until recently, picked up on all changes and improvements that needed to be made. These matters were being addressed but progress had been slow to begin with but was now gathering pace.

A registered manager was employed at the service. 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.

Risk assessments associated with people’s day to day, and personal, risks varied widely in terms of how they were completed and the information about how staff could implement measures to reduce the risks. Information was in some cases incomplete. No harm was reported to have resulted from this. However, this along with other general health and safety risk assessment inconsistencies, posed a potential risk of harm being caused if the necessary information and required risk reduction measures were not made clear for everyone.

There were policies, procedures and information available in relation to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people who could not make some decisions for themselves were protected. The service was making applications to have DoLs assessed, and re-assessed where DoLS approvals were approaching their expiry date. There was a lack of documentary evidence of how this was being followed up. However, we saw that the local authority that mostly places people at the service met with the registered manager recently to discuss what was needed from the local authority to resolve the outstanding applications. Mental capacity was assessed, however, this was not always completed fully in some cases as not all of the required documentation about who was consulted or what had been agreed had been completed.

The care plans we looked at were based on people’s personal needs and wishes and in some cases were good, but not so in other cases. Not all information that was known was recorded clearly to ensure consistency of approach by all staff. People’s personal, cultural, religious and lifestyle preferences were not given sufficient attention in care planning.

There was an organisational policy and procedure for protection of adults from abuse. The service also had the contact details of the London Borough of Camden which is the authority in which the service is located and other authorities who also placed people at the service. Staff said that they had training about protecting people from abuse and this training had been updated, which we verified on training records. We found there were a suitable number of staff on each floor during our visits. Staff were regularly present in communal areas to identify and respond to immediate assistance that people required.

People were supported to maintain good health. Nurses were on duty at the service 24 hours and a local GP visited the home twice each week, but would also attend if needed outside of these times. Healthcare needs were responded to well and we saw that staff supported people to address their medical needs.

Feedback from people using the service showed that the view was mostly of a caring staff group and we saw that staff were respecting people’s dignity and rights. Staff demonstrated compassion in the way that they worked with people.

As a result of this inspection we found two breaches of regulation in respect of Regulations 9 and 12. You can see what action we told the provider to take at the back of the full version of the report.