The inspection took place on 22 and 23 June 2015 and was unannounced. St Thomas provides residential and nursing care for up to 72 older people, including people living with dementia. At the time of our inspection 53 people were living in the home.
The home consisted of four units situated on two floors built round an internal courtyard. Two lifts and stairs provided access to all floors. At the time of our inspection one lift was out of action, but people were able to access both floors using the second lift. People were protected from harm by the use of keypads on exit doors between floors and units. The reception area was manned by a receptionist during office hours, and a walkie talkie was provided for visitors to contact staff when the reception was unmanned.
The home did not have a registered manager. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run. The registered manager had left the service in January 2015. Appropriate actions had been implemented to ensure the home was well managed. The provider had deployed an experienced registered manager from another of their homes to manage St Thomas as an interim measure. They are referred to as the temporary manager in this report. A dedicated manager for this home had been in post for three weeks at the time of our inspection. They had started the process to apply for the registered manager role with the CQC. They are referred to as the new manager in this report.
At the last inspection on 22 and 26 September 2014 we asked the provider to take action to make improvements to ensure that effective measures were in place to address concerns we identified. We found concerns with regards to the management of identified risks to people’s health and welfare, and cleanliness and hygiene in the home. Sufficient staff had not been employed to support people’s needs at all times, and staff had not been appropriately supported through training and supervision to provide people with effective care. At this inspection we found the improvements required had been made.
The provider had taken steps to ensure risks specific to each person had been identified, and actions taken to reduce the risk of harm. The home was clean, and people and others were protected from the risks of cross contamination and health care-associated infection because staff maintained safe hygiene standards.
Staffing levels were sufficient to meet people’s identified needs. Staff had the skills and understanding to meet people’s identified needs effectively. Although staff training had not met the provider’s identified requirement for 85% completion rate, actions were in place to ensure this target would be met by the end of June 2015. Measures were in place to ensure people’s safety was not affected whilst training was refreshed.
Staff had not had the opportunity to attend regular formal reviews of their roles and responsibilities. The new manager had started a programme of supervisory and appraisal meetings. To ensure staff were supported whilst awaiting formal individual meetings, the provider had created opportunities for staff to raise concerns or discuss their development through regular team meetings and the management’s open door policy. Staff told us they felt supported by team leaders and managers.
On the first day of our inspection we found recruitment checks had not been sufficiently robust to protect people from unsuitable staff. When we raised concerns regarding employment gaps and evidence of good conduct with the new manager, they took immediate action to address the shortfalls, and ensure people were not placed at risk of harm.
Appropriate measures were in place to ensure people were not at risk of abuse. Staff understood and followed the process to identify and report safeguarding concerns.
Medicines were stored and administered safely. Nurses followed safe protocols to ensure they identified any risks associated with medicines. Checks ensured medicines were stored safely and accounted for.
Risks affecting people’s health and the home’s environment had been identified, and appropriate measures taken to ensure people, staff and others were not placed at risk of harm. Regular checks and services ensured equipment and fittings remained safe. Staff were trained on the actions to take in the event of an emergency such as fire.
Staff understood and supported people to make decisions about their health and wellbeing. They understood the process of mental capacity assessment and best interest decision-making if the person was assessed as lacking capacity to make specific decisions. Where people’s liberty was judged to be restricted, the temporary manager had followed the requirements of the Deprivation of Liberty Safeguards to lawfully restrict people’s freedom for their own protection.
People were encouraged to eat and drink sufficiently to meet their nutritional needs. Dietary preferences and needs were understood and met. People at risk of malnutrition and dehydration were supported to maintain their nutritional health. Training was being delivered to ensure all staff understood the importance of maintaining accurate records of people’s daily intake.
People were supported to maintain their good health through effective liaison with health professionals, such as the GP and dietician. Documentation was cross referenced to ensure staff were aware of and followed health professionals’ guidance.
People were supported to develop and maintain friendships in the home. Staff treated people with respect and kindness. They involved people in decision making and conversations, and promoted their dignity and privacy. The provider’s values, including recognition of people’s individuality, and promoting independence, respect and dignity, were displayed in the way staff interacted with and supported people.
People’s needs and wishes were documented and reviewed regularly. Staff understood how to communicate effectively with people. They understood gestures and vocalisations used by people unable to verbally explain their care needs. Activities were planned but flexible to encourage people’s participation. The local community was welcomed into the home, and a minibus provided opportunities for people to travel outside.
Relatives said staff were responsive to concerns raised, and kept them informed of changes to people’s needs, and changes in the home. Events such as meetings and social gatherings provided relatives with the opportunity to raise and discuss concerns. Complaints were addressed in accordance with the provider’s policy.
Staff described managers as approachable, and were confident that the new manager would continue to drive improvements in the home. Staff felt valued, and spoke with pride of their achievements. They had opportunities to suggest improvements, and were involved in the evaluation of new practices.
The temporary and new managers led by example, using their experience and knowledge in dementia care to guide and inform staff. This ensured people experienced care that met their diverse and individual needs. Audits carried out by the managers and regional quality team had identified areas for improvement. An action plan held managers accountable for progress and completion. Learning was shared to drive improvements across the provider’s portfolio of homes.