We carried out a review of the data available to us about St Mary's Convent and Nursing Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Mary's Convent and Nursing Home, you can give feedback on this service.
We found the following examples of good practice.
• Visitors agreed a visiting time in advance and visiting procedures were explained to them on the phone. The provider was also including procedures for people visiting in update letters to family and friends.
• Communal areas had been arranged to encourage social distancing. During lockdown the activity team had been instrumental in supporting people to do activities in the garden which promoted social distancing and having one to one sessions with people.
• The provider had up to date guidelines around various areas of coronavirus including increased cleaning schedules and audits and clear procedures for staff and people using the service who had the virus. People returning from hospital visits were supported by staff to self- isolate for a 14- day period.
• The provider felt having clear isolation procedures including prepared boxes of equipment ready in advance, meant that when someone came back from hospital after testing positive, procedures could be immediately implemented. This made staff and people using the service feel safe and reassured them.
• The registered manager understood the need to support people and staff wellbeing. They noted having regular briefings and talking with staff was important to help build staff confidence to undertake their job safely and effectively.
• The provider had a contingency plan in place, was increasing their stock of PPE and kept in regular contact with the local authority.
Further information is in the detailed findings below.
St Mary's Convent and Nursing Home is a care home providing accommodation for up to 60 people who require personal care and support. At the time of the inspection there were 57 people using the service. The service was divided into four units for people who required nursing care and residential care.
People’s experience of using this service and what we found
People received exceptional person-centred care and were supported to have choice and control. Care plans were personalised and recorded people’s preferences, so staff knew how to respond to people’s needs in an effective but sensitive way. There were various activities on offer and people could choose to engage in activities that were meaningful to them. People were supported with their interests and links with the community were maintained. Families were welcomed to the home. There was a complaints procedure in place and the provider responded to complaints appropriately.
The provider had systems in place to safeguard people from the risk of abuse and staff knew how to respond to possible safeguarding concerns. There were also systems in place to identify and manage risks. Safe recruitment procedures were in place and there were enough staff to meet people’s needs. Medicines were managed and administered safely. Staff followed appropriate infection control practices to prevent cross infection.
Supervisions, appraisals and competency testing provided staff with the support they required to undertake their jobs effectively and safely. People's needs were regularly assessed to ensure these could be met. People were supported to maintain healthy lives and access healthcare services appropriately. People were also 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.
People and their relatives consistently told us people were cared for by kind and supportive staff who knew the needs of the people they cared for well. The home was inclusive, respectful and staff went that extra bit further to ensure people were able to live in a way that suited their preferences and needs. People were involved in making decisions about their day to day care and their opinions were listened to and valued. Independence was promoted.
The provider had systems in place to monitor, manage and improve service delivery and to improve the care and support provided to people. People using the service and staff reported the registered manager was approachable and promoted an open work environment. All stakeholders said the home was well led. Clear leadership contributed to people and staff being positive about the management of the home and feeling valued and respected.
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 6 June 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.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
At the last inspection on the 5 and 6 May 2015, the service was rated Good.
This inspection took place on 20 and 21 April 2017 and we found the service remained Good.
Staff understood how to respond to safeguarding concerns and we saw risk assessments and risk management plans to protect people using the service from the risk of harm. There were a number of checks to ensure a safe environment. Safe recruitment procedures were followed and there were enough staff to meet people’s needs.
Medicines were administered safely, but we saw one instance where a care worker administered the medicine and a nurse signed for it. We recommended that the provider develop systems in line with the Royal Pharmaceutical Society guidance on the management of medicines in care homes to ensure the proper and safe management of medicines at all times.
Staff were supported through training and supervision to have the necessary skills to meet people’s needs. The service was very person centred. Staff, professionals and relatives all specifically noted the level of individual care each person received.
The service worked within the Mental Capacity Act (2005) so people were supported in the least restrictive way and had choices.
Nutritional needs were identified and monitored. People enjoyed their meals and had access to food and drink whenever they wanted to.
People’s day to day healthcare needs were met and healthcare professionals confirmed, in their experience, staff had the skills to care for people using the service. End of life care provided by the service was excellent.
We observed staff were kind and caring and knew of people’s preferences. Staff took time to listen and engage positively with people. People’s privacy and dignity were respected.
People and their relatives were involved in care planning and reviews were held regularly. Care needs were assessed and care plans included guidance for staff on how to support people in their preferred way. The service had a number of activities for people to attend and we observed those taking part were interested in the activity they were involved in.
The service had a complaints procedure and addressed complaints appropriately. Everyone we spoke with was satisfied with the service and no one had made a complaint.
The service was well run and the feedback we received indicated the management team were approachable and acted on information received.
The service had systems to monitor the quality of the service delivered including the environment and how the needs of the people using the service were being met.
The service met all the fundamental standards because it continued to provide a high standard of care to people using the service by a competently trained and skilled staff team providing person centred care in a kind and caring manner that involved the person using the service.
Further information is in the detailed findings below.
This inspection took place on 5 and 6 May and was unannounced. At the last inspection on 4 April 2014 we found the service was not meeting the regulations relating to care and welfare, safeguarding, respect and involvement, notifications and records. At this inspection we found that improvements had been made in all of the required areas.
St Mary’s Convent and Nursing Home is a care home providing accommodation for up to 59 older people who require nursing, personal care and support. When we visited, 58 people were living in the home.
There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People using the service told us they felt safe and we saw there were systems and processes in place to protect people from the risk of harm. Staff had received safeguarding training. They understood how to recognise the signs of abuse and knew how to report their concerns if they had any.
People, their relatives and friends told us they were happy with their care. Staff working at the home understood the needs of people and we saw that care was provided with compassion and kindness. People felt included in their care, were listened to and supported to make decisions and choices which staff respected. Throughout the inspection, we observed that staff cared for people in a way that took into account their diversity, values and human rights.
Assessments carried out by the staff ensured that people’s needs were identified and met. Risks were assessed and reviewed to ensure people’s individual needs were being met safely.
Staffing levels were appropriate to keep people safe and meet their needs.
Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff and volunteers began work.
People received their medicines as prescribed and medicines were managed safely.
CQC is required by law to monitor the implementation of the Mental Capacity Act (MCA) 2005 and the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS provides a process to make sure that people are only deprived of their liberty in a safe and least restrictive way, when it is in their best interests and there is no other way to look after them. The service met the requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. Where people did not have the capacity to consent to specific decisions the staff involved relatives and other professionals to ensure that decisions were made in the best interests of the person and their rights were respected.
Staff were well trained, skilled and supported to meet people’s needs. They understood their roles and responsibilities.
People took part in activities and outings of their choice. The activities programme was extensive and took into account people’s diverse needs.
There was a clear management structure at the service and people, staff and families told us that the management team were approachable, inclusive, and supportive. The home had an open and transparent culture, with clear vision and values.
The provider had effective systems in place to monitor the quality of the service so areas for improvement were identified and addressed.
The provider encouraged feedback from people, their relatives and friends, which they used to make improvements to the service.
St Mary’s Convent and Nursing Home is a care home providing accommodation for up to 59 older people who require nursing, personal care and support. When we visited, 57 people were living in the home. The home had a registered manager in post. People living in the home and their relatives commented positively on her “caring nature” and told us she promoted high standards of care.
People we spoke with told us they were happy with the care and support they received. One person said “I am very happy here. We get excellent care. When I want them I call them and they come. Sometimes two or three of them. The sisters are ‘just there’ and I have two daughters who live nearby and visit regularly.” A second person told us “I can’t say enough. I would give them all a medal. Every one of them. They go that one step farther. I don’t call them helpers, they are friends.” A relative also told us “The carers are really caring. My [relative] is prone to fits and they ring me at home whenever she has had one, just to let me know, even though everything is alright.”
We saw most people had the support they needed at lunch time and they were encouraged to make choices about what they ate and drank. However, some people who needed help with eating were not supported in a respectful and dignified way.
The care staff we spoke with demonstrated a good knowledge of people’s care needs. However, the care plans we looked at did not include clear guidance for staff on the care people needed. This meant staff did not have the information they needed to care for and support people in the ways they preferred in a respectful, safe, caring and dignified way.
There was a need to make sure staff understood and followed the provider’s procedure for safeguarding people using the service. Incidents that should have been reported to the local authority safeguarding adults team and the Care Quality Commission were not identified as safeguarding concerns by the home.
We saw all communal parts of the home and some people’s bedrooms, with their permission. We saw the home was clean, hygienic and well maintained.
The problems we found breached health and social care regulations and the action we have asked the provider to take can be found at the back of this report.
We saw that the people who use the service and the staff had developed positive relationships with each other.
People or their representatives were involved in identifying where they needed support and how this was to be provided. This was reflected in the care plans which detailed how people's needs were to be met by the staff.
People received support for their needs from the service and from external health and social care professionals. Within the home they were supported by sufficient levels of staff.
Staff received support and training to ensure they were competent in their work and the care and support they gave to people.
During our inspection we talked with four people who used the service and seven relatives and representatives of people to get their views on what it was like to receive services from the provider. We also talked to four members of staff and four volunteers some of whom previously had relatives who used the service.
All people who talked to us told us the best thing about the home was the standard of care provided to people using the service. One relative said 'Of all care homes, I have seen, St Mary's is the best". Another said if the person they were visiting could not be in their own home, then St Mary's was the next best thing. Relatives and representatives of people said staff monitored people's condition and referred people to various healthcare professionals as required so they received appropriate care and treatment.
People's relatives and representatives confirmed they were involved in the care of people and were kept informed of changes. They said they had seen people's care records when these were drawn up or reviewed. Routines were flexible to support people's individual needs. For example, people were supported to lie in if they wished to do so. People could also chose whether to be in their rooms, participate in activities or relax in communal areas.
We were informed that people in the home were never bored because there was a range of activities to suit everybody's needs whether in house or in the local community. People and their relatives told us of the parties that had been arranged or planned to celebrate various occasions and of the weekly community outings.
People and their relatives reported that staff were appropriately recruited and trained to care for and support people using the service. They all said staff were appropriately supervised by the management team to make sure they did their job to the necessary standard. They told us they could raised concerns to any member of staff and could be sure that their concerns would be addressed without having the need to make a formal complaint.
to manage medicines so that people were protected against the associated risks.
People told us that staff monitored their condition when they were not well and took action where required. They added that they or their relatives have seen their care records. They reported that staff kept them or their relatives informed of changes in their care and treatment. One person said 'staff take my weight, my blood pressure and temperature every month and give me my medicines. Staff call the doctor if I am not well'. Another person said 'this place is out of this world, they would do anything for you'.
People said that all their needs were met in the home including their social and recreational needs. One person said 'we do not sit and gaze at the walls'. Another said 'I do not get bored here and there is always something to do'.
All people said that they made choices for each meal and that their choices were respected by staff. One person said that 'the food is awfully good and you get fresh fruits, ice cream, yogurts'. Another person said 'You put on weight very quickly in here' and a third added 'I have to watch what I eat'.
People said that they trusted staff and management to make sure that they were safe. Some people said that they would speak with their relatives if they had any concerns. Others said that they could speak to any senior member of the management team who would listen to them and address their concern. One person said that 'you can discuss the slightest thing with staff and you can go to any staff if you want to talk to them'.