Archived: St Mary's Care Home

Updated 14 December 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection team consisted of two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

St Mary’s Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to plan our inspection.

During the inspection-

We spoke with 19 people who used the service and 10 relatives about their experience of the care provided. We spoke with eight members of staff including the registered manager, assistant manager, registered nurse, care workers, activities coordinator and the chef.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at the provider’s development plan.

Updated 14 December 2019

St Mary’s Care Home is a care home. The care home can provide accommodation and personal care for up to 60 people in one detached building that is adapted for the current use. The home provides support for people living with a range of complex needs, including people living with dementia. There were 60 people living at the home at the time of our inspection.

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

Some people had experienced safeguarding incidents, but appropriate actions had not always been taken in line with the provider’s safeguarding policy. This inconsistent approach meant that the provider could not be assured that people were always protected from abuse or improper treatment. This was a breach of regulations.

Medicines were managed safely but protocols were not in place to guide staff in when PRN (as required) medicines should be administered. Some people had not received PRN medicines as prescribed and records were inconsistent in identifying how decisions had been made. We have made a recommendation about the management of PRN medicines.

The provider had management systems for monitoring quality. Some systems did not provide effective governance and oversight and had failed to identify the shortfalls that we found.

People and their relatives told us they felt safe at St Mary’s Care Home. One person said, “St. Mary’s is a safe secure place to live.” Risks to people were identified and managed. When people’s needs changed, or things went wrong, risks were reviewed to ensure that lessons were learned. There were enough staff to care for people safely and people were protected by the prevention and control of infection.

Staff received the support and training they needed to be effective in their roles. People and their relatives said they had confidence in the staff. One person said, “The Staff are exceptional and work very hard, you cannot fault them.” Assessments were holistic and care plans provided clear guidance for staff in how to support people’s needs. 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. People were supported to have enough to eat and drink and to access the health care services they needed.

Staff knew people well and supported them to be involved and to express their views. People told us the staff were kind and caring. One person said, “They show such kindness and compassion.” People were treated with dignity and respect and staff knew them well.

People were receiving a personalised service that was responsive to their needs. Improvements had been made in planning activities and it was evident that people’s social needs were supported. One relative told us how their relation, “Really enjoys all the activities, that is good because she is stimulated by them.”

People’s communication needs were identified and supported. People had been supported to plan for end of life care and their diverse needs and wishes were recorded and respected. People told us they knew how to complain and would feel comfortable to do so. One relative told us they would raise concerns with the registered manager, saying, “She listens and acts quickly.”

People, their relatives and staff spoke highly of the management of the home and described the registered manager as approachable. One person told us, “It is a nice well run place and I have a cosy room with a view, I have no worries and everyone around me is nice to me.”

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 27 September 2018). The service remains rated as requires improvement. This service has been rated as requires improvement for the last two inspections.

At this inspection some improvements had been made but we found other areas of practice that needed to improve and one breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating. We have found evidence that the provider needs to make improvements. Please see the safe 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 Mary’s Care Home on our website at www.cqc.org.uk.

We have identified breaches in relation to safeguarding service users from abuse and improper treatment. Please see the action we have told the provider to take at the end of this report.

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.