We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Transcription

1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. St Martins 42 St Martins Road, Bilborough, Nottingham, NG8 3AR Tel: Date of Inspection: 31 October 2013 Date of Publication: December 2013 We inspected the following standards as part of a routine inspection. This is what we found: Respecting and involving people who use services Consent to care and treatment Care and welfare of people who use services Safeguarding people who use services from abuse Management of medicines Safety and suitability of premises Safety, availability and suitability of equipment Requirements relating to workers Supporting workers Assessing and monitoring the quality of service provision Records Inspection Report St Martins December

2 Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activity Broadoak Group of Care Homes Mrs. Samantha Kavanagh St Martin's is a care home located in the Bilborough area of Nottingham and accommodates up to 21 older people including those with dementia type illness. Care home service without nursing Accommodation for persons who require nursing or personal care Inspection Report St Martins December

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 What we have told the provider to do 4 More information about the provider 5 Our judgements for each standard inspected: Respecting and involving people who use services 6 Consent to care and treatment 8 Care and welfare of people who use services 10 Safeguarding people who use services from abuse 12 Management of medicines 14 Safety and suitability of premises 16 Safety, availability and suitability of equipment 17 Requirements relating to workers 18 Supporting workers 20 Assessing and monitoring the quality of service provision 22 Records 24 Information primarily for the provider: Action we have told the provider to take 25 About CQC Inspections 30 How we define our judgements 31 Glossary of terms we use in this report 33 Contact us 35 Inspection Report St Martins December

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 31 October 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with carers and / or family members and talked with staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. What people told us and what we found In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time. People who were using the service or their relatives were not involved in making decisions about their care and support. People's dignity was not always respected. People were provided with sufficient quantities of food and drink. There was not sufficient information in place in people's care plans to assist staff in meeting people's care needs. People were not fully protected from abuse or the risk of abuse because staff did not have the knowledge and information required to do so. Appropriate arrangements were not in place in relation to the management of people's medication. The provider was not carrying out appropriate pre-employment checks before new staff started work. Staff had not received all appropriate training. Staff were receiving regular supervision however it was not being utilised effectively. The provider did not have an effective system in place to assess and monitor the quality of the service provided. Accurate records were not being maintained in respect of the care being provided to each service user. You can see our judgements on the front page of this report. What we have told the provider to do We have asked the provider to send us a report by 17 December 2013, setting out the Inspection Report St Martins December

5 action they will take to meet the standards. We will check to make sure that this action is taken. Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take. More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report St Martins December

6 Our judgements for each standard inspected Respecting and involving people who use services People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Our judgement The provider was not meeting this standard. People's views and experiences were not taken into account in the way the service was provided and delivered in relation to their care. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement People who were using the service or their relatives were not involved in making decisions about their care and support. People's dignity was not always respected. We used a number of different methods to help us understand the experiences of people who used the service, because the majority of people had complex needs which meant they were not able to tell us their experiences. We spoke with one relative about the service who said, "I have no complaints with the staff, they are on top of [the person's] needs." We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We conducted a SOFI observation for 40 minutes at the lunchtime period. We also carried out observations of the support people received at breakfast time and at other times during our inspection. We observed that people were not engaged in decisions relating to their care. During the breakfast and lunchtime periods, we saw meals being placed in front of people with limited communication from the staff. We observed people being hurried and instructed to eat with little consideration by the staff of people's individual eating styles and preferences. We observed one person who was capable of eating independently being fed by staff when the person did not respond to the instructions to continue eating. This meant that the service was not treating people with consideration and respect. We observed that the service lacked understanding of the impact people's illnesses and disabilities may have on their ability to eat independently. We observed people living with dementia who attempted to eat their meals with their hands or using cutlery not from their place setting being spoken to inappropriately by staff and having cutlery repeatedly put back into their hands. However we did also see some more positive communication used by one member of staff. This staff member sat down next to the people they were Inspection Report St Martins December

7 supporting at that time and spoke in a more calm and considerate manner. There was a lack of engagement by the service for people living with dementia who exhibited repetitive behaviour or were beginning to lose the ability to verbally communicate coherently. These people were at times segregated from other people within the home. We observed lack of consideration by staff for people with limited sight, with food and drinks placed in front of them without communication from the staff. This meant that the service was not considering people's illnesses or disabilities when delivering care. We spoke with two staff about how they engaged people in making decisions about their care. One member of staff said, "[People] are allowed to look at their care plans. Their choices are limited, but everyone gets the same." The other staff member said, "People get choices, they just have to be reminded." We looked at the care plans for four people who used the service. A care plan should describe a person's needs and give guidance to staff in how to meet those needs and people should have the opportunity to be involved in their care plan. We found that people or their representatives were not routinely able to be involved in decisions about their care. This meant that the provider was not enabling people to be involved in making decisions regarding their care and treatment. We observed that the care records had a checklist that identified people's equality and diversity needs. We saw that this information was not fully reflected within the care records. Where specific guidance to staff was indicated in the care records to meet people's diverse needs, we did not observe staff following these specific instructions. This meant that people were not being treated with dignity due to their diverse needs not being respected. Inspection Report St Martins December

8 Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was not meeting this standard. Where people did not have the capacity to consent, the provider had not acted in accordance with legal requirements. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We had not planned to inspect this outcome area however our findings on the day of our inspection meant we have included it in this report. We used a number of different methods to help us understand the experiences of people who used the service, because the majority of people had complex needs which meant they were not able to tell us their experiences. Where people did not have the capacity to consent, the provider had not always acted in accordance with legal requirements. We looked at the care records for four people who were using the service. We found the care records to be confusing and sometimes contradictory. We saw statements on care plans which indicated people had consented to on-going care and treatment. However, we found generic Mental Capacity Act 2005 (MCA) two stage tests and best interest checklists which indicated that people were unable to participate in their care planning and reviews. The MCA provides a legal framework to empower and protect people who may lack capacity to make some decisions for themselves. The MCA also provides a nonexhaustive checklist of factors that decision-makers must work through in deciding what is in a person's best interests. The MCA assessments that we saw had been carried out by the previous manager. We spoke with the manager on the day of our inspection who told us they had not been trained in assessing people's mental capacity within the framework of the MCA. This meant there was a risk that people's rights under the MCA may not be fully protected. The manager advised us that they would seek external support until such a time as they were appropriately trained. We read on one person's care plan that the home had requested involvement of an Independent Mental Capacity Advocate (IMCA) when making decisions in this person's best interest. An IMCA is an independent person who represents vulnerable people who lack capacity to make important decisions regarding medical treatment and Inspection Report St Martins December

9 accommodation, where the person had no family or friends available for consultation about those decisions. We saw that a recent decision regarding the person's residency within the care home was made without the involvement of an IMCA. We spoke with the manager who told us that that decision was made without considering the MCA and had not involved an IMCA in the decision because they had been unable to access an IMCA. This meant that the provider was not complying with the MCA when making care and treatment decisions in a person's best interests. We saw that another person's care records included an instruction form for Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). The DNACPR form is a means of communicating the decision to those responsible for providing emergency cardiopulmonary resuscitation (CPR) treatment. CPR can sometimes re-start the heart and circulation of blood and/or breathing following a cardiac and/or respiratory arrest. The DNACPR form did not demonstrate that the consent of the person had been sought. It was not clear to see if there had been consideration of whether or not the person had the capacity to make the decision regarding resuscitation. Whilst the contact details for a medical professional had been included on the form, the form was not completed fully. The form may create confusion about the validity of the decision and increase the risk of a healthcare professional not carrying out the person's end of life wishes. We saw that when staff members interacted with people, these interactions were task driven and they did not always provide people with explanations before supporting them with their care. We observed staff were not always asking people for their consent before assisting them. Inspection Report St Martins December

10 Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was not meeting this standard. Care and treatment was not planned and delivered in a way that was intended to ensure people's safety and welfare. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We used a number of different methods to help us understand the experiences of people who used the service, because the majority of people had complex needs which meant they were not able to tell us their experiences. We used the SOFI (Short Observational Framework for Inspection) tool during the visit. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. We conducted a SOFI observation for 40 minutes over lunchtime. We also observed during the breakfast period and at other times during our inspection. During our observations, we saw limited staff interactions with people and a general lack of awareness of people's individual needs. We saw staff who were assisting people to eat did not engage with the person they were assisting and were often distracted by other people in the dining room. People were offered a choice of meals and those who ate all or most of their meal were offered second helpings. Staff supported people's hydration throughout the meal by continually filling up juice glasses when people had finished. We had identified one person required a special diet and we saw this was provided as detailed in their care plan. We saw that when one person started to get anxious, staff intervened quickly to calm the situation. We spoke with the manager regarding the activities planned for the day. They told us there were armchair based activities planned for the morning and different activities for the afternoon. In between the activities the majority of people were sitting passively for long periods. We spoke with staff regarding activities for people. One staff member said, "We've got those who are more able bodied, it's nice to converse with them. People with high needs, we can't converse with." Staff also told us they try to fit activities around their care tasks. Our observations indicated people's social needs were not being fully met. We spoke with two members of staff and asked them about the care needs of people who used the service. They were able to give us a description of individual care needs and how Inspection Report St Martins December

11 they supported people. The staff we spoke with told us they felt they worked well together and communicated well. People's needs were assessed but care was not planned and delivered in line with their individual care plan. We looked at the care plans of four people who were using the service. A care plan should describe a person's needs and give guidance to staff in how to meet those needs. We saw that the care plans appeared to be generic and did not always provide information specific to the needs of individual people. For example one person's care plan stated that they may sometimes present behaviour that would challenge staff. However the care plan did not describe why this might happen and what staff could do to manage the situation should it arise. This meant that staff did not always have access to adequate information about people's care needs. Care plans were being reviewed on a monthly basis however there was little evidence of changes being made to people's care plans. Where a change had been made there was not consideration of how the change might impact on other areas of the care plan. We had concerns that one person's fluid intake was consistently low and we did not see evidence that staff had taken action to address this concern. According to information in the person's care plan staff should have been supporting the person to drink approximately 1.4 litres of fluids per day. However this person had not achieved the target consistently over a period of several weeks. The manager was not aware if any action had been taken to address this concern. This meant that appropriate action had not been taken to address a concern about a person's well-being. One person had been living at the home for about four months on a respite care package. The manager told us they had become a permanent resident however this person did not have a proper care plan in place. Staff only had access to basic information on one side of paper. This meant that staff did not have access to adequate information about this person's care needs. We saw that the service had made referrals to external healthcare professionals where they felt additional support was required. For example the local dementia outreach team had provided guidance about the care needs of some people using the service. Also a dietician had provided advice where staff had concerns about a person's weight loss. Inspection Report St Martins December

12 Safeguarding people who use services from abuse People should be protected from abuse and staff should respect their human rights Our judgement The provider was not meeting this standard. People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We used a number of different methods to help us understand the experiences of people who used the service, because the majority of people had complex needs which meant they were not able to tell us their experiences. We spoke with two staff working in the home and they told us they had received recent training in how to safeguard vulnerable adults from abuse. The training records we observed confirmed this. However, the staff we spoke with were not able to tell us how they would contact the local safeguarding authority. One staff member said, "I report concerns on the daily logs, or I report it to my senior for the handover." They also told us they would document concerns in people's daily logs. We observed the contact numbers for the local safeguarding authority displayed around the home. This meant that the provider was not ensuring staff were suitably trained and competent to safeguard people against the risks of abuse. During our visit we had concerns about whether people who use the service were protected from the risk of abuse, because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. We saw that some people using the service had behaviour which staff may find difficult to manage. We looked at the care records for one person who was described by staff as sometimes displaying behaviours which staff may find difficult to manage. We found there was no care plan detailing what might trigger this or how staff should respond to it. We saw that staff were completing 'ABC' charts, which were used by the home to record any incidents of challenging behaviour. However, we did not see how this information was being used to support the person. An ABC chart is used to document what happened before, during and after an incident in order to try and understand what may have caused it and how it may be managed in the future. We looked at the safeguarding policy that was in use at the home. This contained a bullet Inspection Report St Martins December

13 pointed list of the different types of abuse that may occur, however it did not detail every possible kind of abuse. There was no description of each type of abuse. We did not see any evidence to confirm that staff had read and understood this policy. This meant that staff had not been provided with all the information needed in relation to safeguarding people from abuse. Inspection Report St Martins December

14 Management of medicines People should be given the medicines they need when they need them, and in a safe way Our judgement The provider was not meeting this standard. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We did not ask people who used the service for their opinion about the management of medication. We gathered evidence by looking at the storage, recording and administration of medication. We found mixed evidence about how medicines were managed safely. Appropriate arrangements were not in place in relation to the recording of medicine. We looked at the medication administration records (MARs) for five people who used the service. We found inconsistencies in the way medication was being recorded. We saw that there were some gaps on the MARs where no record had been made to confirm if the medication had been administered or not. We saw that there were signatures on the MARs to indicate the medication had been administered and the medication was still contained within the blister pack. This meant staff were not following medicines management procedures effectively and people may not be receiving their medication as prescribed. There was a basic system in place to store and return any unused medication to the local pharmacy. However this system did not appear to be working effectively. We saw loose medication in the bin which should only be used for the safe storage of sharps. This meant that the medication could not be accounted for. We saw some eye drops were being used after the expiry date. This meant that people were at risk of having medicines administered which were ineffective. We saw that for some people who were administered medication to help alleviate the impact of their dementia on their wellbeing, medication was not being administered regularly. We saw that for these people, medication was not being administered due to them being asleep. We spoke with the manager who was not aware of this issue. This meant that there was a risk to these people's wellbeing due to the inconsistent administration of their medicines prescribed to alleviate the impact of their dementia. We saw that staff were recording the minimum and maximum temperatures for the medicines fridge. However, we saw that the recorded temperature was often above the recommended maximum for storage of these medicines. Where certain types of medicines Inspection Report St Martins December

15 are stored at temperatures above 8 degrees centigrade this can reduce the effectiveness of some medicines, or it may increase the potency of others. This meant that people were at risk of having medicines administered that were either ineffective or of increased potency. The training records that we were provided with showed that three members of staff were overdue their refresher training on the safe handling of medication. This may mean that these staff did not have the skills required to safely handle and administer medication. The manager told us that they sometimes observed staff whilst they were administering medication, however we did not observe records of this. We looked at the controlled drugs kept in the home and found that the stocks of controlled medicines matched the records of administration. Controlled drugs are a group of medicines that have the potential to be abused. For this reason, the handling of these drugs is subject to certain controls set out in law. This meant that people were protected by staff practices in managing the stock of controlled medicines. Inspection Report St Martins December

16 Safety and suitability of premises People should be cared for in safe and accessible surroundings that support their health and welfare Our judgement The provider was not meeting this standard. People who use the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We had not planned to inspect this outcome area however our findings on the day of our inspection meant we have included it in this report. We did not ask people who used the service for their opinion about the safety and suitability of the premises. We gathered evidence by looking at the records of checks performed by the provider. We also carried out a tour of the building to check whether effective systems were in place to ensure the premises were safe for people who used the service, staff and visitors. We found mixed evidence about how the provider was ensuring the premises were safe and suitable. We found the garden looked unkempt, unwelcoming and difficult for people to access. We saw the external window frames did not appear to have been recently repainted and there was evidence of wood rotting. Some people's rooms were cold with the drafts through the windows. This meant that the windows were not effective at preventing drafts and may compromise the security of people in these rooms. We were told by the manager that the windows were due to be replaced over the coming weeks. We found the building looked tired and dated, with basic decoration which did not create a feeling of homeliness. We saw that people's bedding looked old and was thin with repeated usage. We saw that carpets were thin in places where they had been frequently walked over. We found areas of malodour in the main lounge, around the downstairs bathroom and on the first floor of the building. We saw the floor was lifting in a shower room. We observed holes in the walls which had not been repaired. This meant the provider had not taken suitable steps to ensure the premises were pleasant, comfortable and homely for people living there. On the ground floor, we saw there was one toilet, which was also the main bathroom, available for 17 people. We saw that several incontinence products were being kept in the bath. The majority of the people using the service spent most of their day in the downstairs area. This meant that there were not sufficient facilities available to ensure people's comfort when in the downstairs area of the home. Inspection Report St Martins December

17 Safety, availability and suitability of equipment People should be safe from harm from unsafe or unsuitable equipment Our judgement The provider was not meeting this standard. People were not fully protected from unsafe or unsuitable equipment. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We found mixed evidence about how the provider was ensuring the safety, availability and suitability of equipment. We did not ask people who used the service for their opinion about the safety and suitability of the premises. We gathered evidence by looking at the records of checks performed by the provider and speaking with staff. We spoke with staff who told us they were trained to use the equipment within the home. The training records we were provided with confirmed that staff had received manual handling training. One member of staff told us they thought there was sufficient equipment to meet people's needs. We looked at the equipment maintenance records for the past year. We found evidence of routine maintenance and servicing that had been carried out on equipment such as the hoist, slings and the specialist bath. We looked at the provider's arrangements for the maintenance of services to the home. We found evidence of checks of the passenger lift, fire extinguishers, fire alarm system, electrical installation and the systems for dealing with waste. However, we found no evidence of recent checks of the nurse call system and the gas safety of the boiler. We spoke with the manager who told us that the provider arranged these checks. This meant that there was a risk that people were not fully protected from issues with the services and systems in the building due to lack of necessary checks having taken place. We spoke with the manager regarding the testing records for portable electric equipment in the home. They told us this was arranged annually by the provider. We saw records of the last testing that occurred in April The manager showed us a timetable indicating that the testing for the home was due to start on the 1 November Inspection Report St Martins December

18 Requirements relating to workers People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was not meeting this standard. People could not be sure they were being cared for, or supported by, suitably qualified, skilled and experienced staff. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We did not ask people who used the service for their opinion about the recruitment procedures used by the service. We gathered our evidence by looking at staff files, talking with the manager and with staff. Appropriate checks were not being undertaken before staff began work. We looked at the files of four recently recruited members of staff. We saw that the recruitment procedure was not sufficiently robust and appropriate steps had not been taken to check each person's suitability for the role of a carer. The application form used by the provider did not allow sufficient space for the candidate to record their skills and previous work experience. This meant that the information provided by each candidate was basic. Interview notes were only present in two out of the four staff files. The notes were basic and did not appear to make use of an interview assessment and scoring template. Therefore we could not be assured that the interviewer had carried out an appropriate assessment of the candidate's ability to do the job they had applied for. Checks of each staff member's identification had been carried out. For three out of the four staff members a criminal records check had been carried out with the Disclosure and Barring Service (previously known as the Criminal Records Bureau) and received prior to the start date given to us by the manager. For one member of staff this was received after the start date we were given. However a preliminary check had been carried out to ascertain whether this staff member had previously been barred from working with vulnerable adults. We saw that not all staff members had received references before they had started work. Where a reference had been received it was not always from the previous employer. References did not always clearly indicate in what capacity the person knew the staff member. This meant the provider had not sought all relevant assurances about the suitability of the people they were employing. We spoke with one member of staff regarding the checks performed prior to their starting Inspection Report St Martins December

19 employment. They told us they had a CRB check and references were taken prior to their starting employment with the service. Inspection Report St Martins December

20 Supporting workers Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was not meeting this standard. People were cared for by staff who had not been supported to deliver care and treatment safely and to an appropriate standard. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We did not ask people who used the service for their opinion about the support provided to staff. We gathered our evidence by looking at training and supervision records and speaking with the manager and staff. Staff were not receiving appropriate professional development. We looked at the training records that were given to us by the manager. These indicated that staff were provided with training in a variety of areas relevant to the job role of the care staff. For example training was provided in infection control, safeguarding vulnerable adults and manual handling. The records showed that several staff were overdue a refresher of training courses. All staff were overdue training in managing behaviour that can challenge and dementia care. This training is relevant to the service as many of the people using the service had a type of dementia. The training records also showed that some staff were overdue refresher training in infection control, manual handling and first aid amongst others. We spoke with two members of staff regarding the training they received. They both told us they felt the quality of the training was good and that they had all the training they needed. One staff member said, "Training is on-going." The other staff member said, "I always take something away from the training." We looked at the supervision records for all staff that were provided to us by the manager. These showed that generally staff received a supervision meeting once every three months. However supervision records were generally similar in their content and did not appear to raise any issues or set any meaningful targets for staff to work towards. The supervision records we saw did not appear to have raised the issues that we found during our inspection. This meant that the supervision process was not being utilised effectively. We spoke with staff regarding their supervision. They told us they felt supported by the manager. One staff member said, "Supervision is all through the day. I get a formal sit down every three months. We look after each other." The other staff member said, "The Inspection Report St Martins December

21 manager takes me to one side if something needs to change. I can always go to the manager." Inspection Report St Martins December

22 Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was not meeting this standard. The provider did not have an effective system to regularly assess and monitor the quality of service that people receive. The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement People who use the service, their representatives and staff were asked for their views about their care, however we did not see how they were acted on. We saw relatives of people who used the service had completed annual questionnaires. We saw that the responses were all generally positive. Where issues had been identified, we did not find evidence of actions being taken by the service. This meant that, whilst the provider was gathering feedback on the quality of the service, they were not always acting on the information being provided. We saw minutes of relatives and residents meetings, which were occurring on a regular basis. We saw that relatives were recorded as not attending the meetings, and that they were spoken with individually by the manager. We saw there were attempts by the service to ask people for their views of the service during these meetings. We spoke with two members of staff regarding how the service was assessing the quality of the service provision. One member of staff said, "I'm not aware of any audits, surveys or meetings. If there are any problems, the manager's door is always open." The other staff member said, "I don't know if audits take place." We saw the minutes of staff meetings, which were held every month. We saw discussions were centered on what was not working in the home and how the staff were to work around the difficulty. This meant that whilst staff were being involved in the running of the service, they were not being asked for their feedback on the service provision. We asked the manager for any audits they had completed at the home to monitor the quality of the service. We found that whilst the manager had completed daily audits on the condition of the environment and equipment, they had not identified any of the issues we found during our inspection. The manager was carrying out regular audits of medication Inspection Report St Martins December

23 administration. However these audits had not picked up the issues we found during our inspection. This meant that the provider and manager did not have effective systems in place to identify, assess and manage risks to the health and safety of people who use the service and others. We had concerns in relation to the planning and delivery of care for some people using the service. We spoke with the manager regarding the issues we found with the care plans. They told us they did not audit the care records in terms of the quality and relevance of information they contained. This meant that the manager did not have effective systems in place to identify, assess and manage risks to the welfare of people who use the service through inaccuracies in people's identified plan of care. We found areas of concern in relation to other outcomes of the essential standards of quality and safety. The manager or provider had not identified these areas of concern. There was a complaints procedure displayed in the home however this was out of date and contained incorrect contact details for external agencies. A statement of purpose was placed in some people's bedrooms however this contained the name of manager no longer employed at the service. This meant people were not always provided with up to date information about how to raise concerns about the service. Inspection Report St Martins December

24 Records People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was not meeting this standard. People were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. We have judged that this has a moderate impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement We had not planned to inspect this outcome area however our findings on the day of our inspection meant we have included it in this report. We looked at a variety of records and found the service did not have clear procedures that were followed to ensure personalised records and medical records were always kept and were fit for purpose for each person who was using the service. We found gaps and inconsistent information in the care plans, daily observation records and night care records. We found gaps in the daily observation records for food and fluid intake. Fluid intake charts did not provide a total amount of fluid that each person had taken each day. We found night care records did not indicate when people were being repositioned to help protect their skin from pressure damage. We found instructions in care records were not individual, person-centred and did not consider the abilities of the person. Where changes to care needs had been identified, we found the care records had not been always been updated to reflect these changes. This meant there was a risk that people would not be adequately protected because some documents about the care and treatment provided to people had not been completed or updated properly. Inspection Report St Martins December

25 This section is primarily information for the provider Action we have told the provider to take Compliance actions The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 17 HSCA 2008 (Regulated Activities) Regulations 2010 Respecting and involving people who use services How the regulation was not being met: Suitable arrangements were not in place to ensure the dignity and independence of service users. Service users were not enabled to make, or participate in making, decisions relating to their care. Regulation 17 (1) (a) and (b). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 18 HSCA 2008 (Regulated Activities) Regulations 2010 Consent to care and treatment How the regulation was not being met: Suitable arrangements were not in place to establish and act in accordance with the best interests of the service user. Regulation 18 (1) (b). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Care and welfare of people who use services How the regulation was not being met: Proper steps had not been taken to ensure that each service Inspection Report St Martins December

26 This section is primarily information for the provider user is protected against the risks of receiving care that is inappropriate or unsafe by means of the planning and delivery of care in such a way as to meet the service user's individual needs and ensure the welfare and safety of the service user. Regulation 9 (1) (b) (i) and (ii). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010 Safeguarding people who use services from abuse How the regulation was not being met: Suitable arrangements were not in place to ensure that service users are safeguarded against the risks of abuse by means of taking reasonable steps to identify the possibility of abuse and prevent it before it occurs. Regulation 11 (1) (a). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010 Management of medicines How the regulation was not being met: Service users were not protected against the risks associated with the unsafe use and management of medicines, by means of the making of appropriate arrangements for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration and disposal of medicines used for the purposes of the regulated activity. Regulation 13. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 Safety and suitability of premises How the regulation was not being met: Service users and others having access to the premises were not protected against the risks associated with unsafe or Inspection Report St Martins December

27 This section is primarily information for the provider unsuitable premises by means of appropriate measures in relation to the security of the premises, adequate maintenance and the use of any surrounding grounds. Regulation 15 (1) (b) and (c) (ii). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 16 HSCA 2008 (Regulated Activities) Regulations 2010 Safety, availability and suitability of equipment How the regulation was not being met: Suitable arrangements were not in place to protect service users and others who may be at risk from the use of unsafe equipment by ensuring that equipment provided for the purposes of the carrying on of a regulated activity is properly maintained and suitable for its purpose. Regulation 16 (1) (a). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 21 HSCA 2008 (Regulated Activities) Regulations 2010 Requirements relating to workers How the regulation was not being met: Effective recruitment procedures were not being operated in order to ensure that no person is employed for the purposes of carrying on a regulated activity unless that person is of good character and has the qualifications, skills and experience which are necessary for the work to be performed. Regulation 21 (a) (i) and (ii). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Supporting workers How the regulation was not being met: Suitable arrangements were not in place in order to ensure that persons employed for the purposes of carrying on the regulated Inspection Report St Martins December

28 This section is primarily information for the provider activity are appropriately supported in relation to their responsibilities to enable them to deliver care to service users safely and to an appropriate standard by receiving appropriate training, professionall development, supervision and appraisal. Regulation 23 (1) (a). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service provision How the regulation was not being met: Service users were not protected against the risks of inappropriate or unsafe care by means of the effective operation of systems designed to enable to registered person to regularly assess and monitor the quality of the services provided in the carrying on of the regulated activity. There was not an effective system in place to identify, assess and manage risks relating to the health, welfare and safety of service users and others. Regulation 10 (1) (a) and (b). Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 Records How the regulation was not being met: Service users were not protected against the risks of unsafe or inappropriate care arising from a lack of proper information about them by means of the maintenance of an accurate record in respect of each service user which shall include appropriate information and documents in relation to the care provided to each service user. Regulation 20 (1) (a). This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us by 17 December CQC should be informed when compliance actions are complete. Inspection Report St Martins December

29 This section is primarily information for the provider We will check to make sure that action has been taken to meet the standards and will report on our judgements. Inspection Report St Martins December

30 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report St Martins December

31 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report St Martins December