We carried out a review of the data available to us about St Mary's Haven 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 Haven, you can give feedback on this service.
St Mary’s Haven is a residential care home providing personal care. The service can support up to 46 people. At the time of this inspection there were 31 people living in the service. Some of these people living in St Mary’s Haven are living with dementia.
People’s experience of using this service and what we found
People told us they were happy with the care they received and people said they felt safe living there. One person said; “Staff are good and come when I need them." Another said; “The care, devotion and empathy given by staff was outstanding.” One professional said; “I go to a lot of homes and this is a nice one.” People looked happy and comfortable with staff supporting them. Staff were caring and spent time chatting with people as they moved around the service.
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 by staff who completed an induction, training and were supervised. Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction and activities with staff. Staff knew how to keep people safe from harm.
The environment was safe, with upgrades ongoing and people had access to equipment where needed. A recommendation, about pictorial signage to help support people who needed orientation to their surroundings, made at the last inspection is in the process of being actioned.
Improvements had been made to the way medicines were managed, and people received their medicines safely in the way prescribed for them. We made a recommendation about the way medicines were stored to make sure they were always kept at the correct temperature.
Staff received appropriate training and support to enable them to carry out their role safely, including fire safety and mental health training.
People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.
Records of people's care were individualised and reflected each person’s needs and preferences. Risks were identified, and staff had guidance to help them support people to reduce the risk of avoidable harm. People’s communication needs were identified, and where they wanted, people had end of life wishes explored and recorded.
People were encouraged by staff to eat a well-balanced diet and make healthy eating choices. Special diets were catered for.
People were supported by a service that was well managed. Records were accessible and up to date. The management and staff knew people well and worked together to help ensure people received a good service.
Staff told us the registered manager of the service was approachable and listened when any concerns or ideas were raised. One staff member commented that the registered manager was ‘very supportive’.
People and their families were provided with information about how to make a complaint and details of the complaint’s procedure were displayed at the service.
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 (published 29 February 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an unannounced inspection of this service on 16 January 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when they would have complied with Regulation 11, Need for consent, Regulation 12, Safe care and treatment, Regulation 17, Good governance and Regulation 18, Staffing.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-led which contain those requirements.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires improvement to Good. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St. Mary’s Haven on our website at www.cqc.org.uk.
Follow up
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.
St Mary’s haven provides accommodation with personal care for up 46 people. There were 38 predominantly older people using the service at the time of our inspection. Since the last inspection the service had extended the premises to accommodate people living with dementia. The recent temporary closure of another home in the Anson Care Group had led to 10 people and the staff moving to St Mary’s Haven whilst extensive building work took place. This led to two registered managers working together at St Mary’s Haven.
People’s experience of using this service and what we found:
Risks relating to people’s care needs were not always well managed. Where risks had been identified risk assessments were not always carried out to guide and direct staff on how to reduce them. People’s money, held by the service, had not been audited since July 2019.
Staff were not always trained to support people with specific health conditions. Some people living at the service had long term conditions such as epilepsy and diabetes, which required specific care and support. Guidance and direction were not always provided in care plans for staff on how to meet their needs.
Some people required specific monitoring. For example, food and drink intake, blood sugar monitoring or skin condition checks. Paper records used by staff, despite an electronic system being in place, contained many gaps.which meant we could not be certain they received the care needed to meet their needs safely.
Staff were not always being provided with supervision in line with the policy held by the service.
Staff received training. However, some mandatory training was not up to date. The registered manager confirmed, “No I don’t think any staff have had epilepsy training.” We were not provided with evidence that showed this training was scheduled in the near future.
The handover sheet used by staff to communicate information about people at shift changes was not up to date on the day of inspection. This placed people at risk of inappropriate care as staff did not have accurate up to date information.
The white board, used to record important information about people’s care needs in the manager’s office did not contain accurate up to date information.
The registered manager was not clear on elements of the Mental Capacity Act 2005. Information held on the white board regarding the Lasting Powers of Attorney held by people living at the service was not accurate.
People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; however, the policies and systems in the service did not support this practice.
There was not an effective process in place to monitor people’s Deprivation of Liberty status (DoLS) and when reviews were due. The registered manager did not have accurate information on which people had an authorisation in place.
Care plan reviews had taken place repeatedly in the past without key information and risk assessments being checked as present, accurate or updated as needed.There was no consistent system or process in place for staff to record information relating to people’s care. Staff were recording information in different places, such as on the computer system, on paper charts and in one case, a separate book. All the monitoring records we reviewed contained gaps. No management oversight of these records was taking place.
Concerns identified, and recommendations made at the previous inspection continued to be a concern at this inspection.
Guidance provided for staff in some sections of the care plans was inaccurate and conflicting.
Oversight and governance arrangement of the service provided was not effective. Two registered managers and a head of care worked in the service yet had failed to identify the concerns found at this inspection.
Audits were not robust. New processes put in place by the new registered manager were not being effectively implemented.
Infection control measures were in place to prevent cross infection. However, the registered manager did not carry out any recorded audits on infection control to check if any improvements were required. The service appeared clean.
One staff meeting had been held for each staff team since the new registered manager took up their post in June 2019. The meetings were used to remind staff of best practice. Some issues raised at these meetings had not been effectively actioned.
The premises had been recently extended and refurbished. There were slopes in corridors which did not have any warning signs alerting people to this change in floor level. There were no hand rails to support people using the corridors where slopes were present. Toilets and bathrooms had only standard signage. No pictorial signage was in place in the dementia unit to help support people who needed orientation to their surroundings.
People received their medicines as prescribed. Medicine audits were not effective, as concerns identified were not addressed. Records were poorly completed by staff when they applied prescribed creams.
People and their relatives said they felt their loved ones were safe with the staff supporting them.
Staff were recruited safely in sufficient numbers to ensure people’s needs were met.
People told us, “I am happy here, staff are good” and “I am alright here”
Relatives told us, “I am happy that [Person’s name] is happy” and “I think it is a good place.”
People were able to make choices about their life and how their care and support were provided. People’s preferences were reflected in people’s care plans. Staff understood the importance of respecting people’s wishes and choices.
People and relatives agreed the staff were kind and caring. Staff respected people’s diverse characteristics and were clear that each person’s individual needs were their priority. People told us they felt listened to and their privacy and dignity were respected.
There were activities provided for people seven days a week. A shared minibus enabled people to access the local community.
Records were stored appropriately and accessible. However, information was not always held in a consistent manner making it difficult to find specific information when needed.
Visiting healthcare professionals told us, "It is often difficult to obtain entry to the service." The provider had implemented a measure whereby all visitors must ring the bell to be allowed in to the service. The provider was aware there had been a fault with the outer door which had led to people having to wait and was rectifying this. Comments also included, “We find documentation is a problem sometimes, it is not always easy to establish if something has taken place. When something happens with a person there is often no sign of it in their care plan” and “I don’t think that the home is really working as well as it could just at the moment. We don't have any concerns about people's care."
Systems were in place to deal with concerns and complaints.
Two staff teams had recently merged during the temporary closure of one home in the Anson care group. Staff told us they enjoyed working at the service and that the teams worked well together.
Rating at last inspection and update:
The last rating for this service was requires improvement (report published 28 January 2019) and there were two breaches of regulation. The service has been rated requires improvement for the last two inspections. One of these inspections was under the previous legal entity, although still under the same provider. At this inspection we found insufficient improvements had been made and the provider continued to be in breach of the regulations.
Why we inspected:
This was a scheduled inspection to review the action taken by the provider following our previous inspection.
You can see what action we have asked the provider to take at the end of this full report.
We found no evidence during this inspection that people remained at risk of harm from this concern. Please see the safe, effective, responsive and well-led sections of this full report.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Follow up:
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.
Prior to this inspection the Care Quality Commission (CQC) had received some anonymous concerns alleging low staffing levels, poor staff morale, poor cleanliness of the service, concerns about the management and allegations of care provided to some people by some staff. This inspection was bought forward to look at these concerns. The provider and registered manager were aware of some of the recent concerns raised to CQC. These had been fully investigated and appropriate disciplinary action had been taken against specific staff members. Where it had been alleged that some staff had provided poor care to some people we spoke with those people and did not find any evidence to substantiate the concerns raised.
St Marys Haven is a care home which offers care and support for up to 34 predominantly older people. At the time of the inspection there were 31 people living at the service. Some of these people were living with dementia. The service is made up of two units and occupies a detached building. There were passenger lifts to provide people with access to the upper floors.
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.
During this inspection spent time in the communal areas of the service. Staff were kind and respectful in their approach, they knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect.
One part of the service, which was unoccupied, was undergoing extensive renovations. The provider had taken steps to help ensure people were protected as far as possible from any disturbance resulting from this work. St Marys Haven provides care for people with dementia, however, there was no pictorial signage to support people who were living with dementia, who may require additional support with recognising their surroundings. The provider assured us this was being addressed with the building work which was planned to enhance the environment for people living with dementia.
We walked around the parts of the service, where people lived, and they appeared clean and were well maintained. There were no odours throughout the service. The premises were regularly checked and maintained by the provider. There were two cleaning staff on duty on the day of this inspection. Equipment and services used at St Marys Haven were regularly checked by competent people to ensure they were safe to use.
Care plans were held electronically. Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible. Care planning was reviewed regularly and people’s changing needs were recorded. However, the front page of some care plans, detailing people’s needs, had not been updated at reviews. This meant some misleading out of date information was highlighted which could have misinformed staff. Daily notes were completed by staff, however, we noted there was sometimes a delay in staff entering details of the care provided on to the electronic systems. There were gaps in some people’s records. This meant, at times, it appeared that some people had not received any care or support for many hours, when we were assured that they had. Both of these issues were addressed during this inspection.
We have made a recommendation about this in the Responsive section of this report.
The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. We checked the staffing rota for periods prior to and after the inspection and saw the planned number of staff were scheduled to work, or had worked. Some staff had left the service recently and there were staff vacancies at the time of this inspection. The vacant posts were being covered by existing staff and some agency staff. Staff told us they were happy working at the service, that morale was good, and that they felt well supported by the management team. Staff were supported by a system of induction training, supervision. Appraisals were scheduled to take place in the coming months. The registered manager was supported by the provider and a team of motivated and some long-standing staff.
Medicines were not always managed in a safe and effective way. While audits had highlighted errors in recording when medicines were administered this had not been followed up by any effective and robust actions to address the failings. One person had missed some of their prescribed medicines. Some concerns found at this inspection had been identified at the previous inspection of St Marys Haven. The registered manager had not addressed these concerns effectively.
Meals were bought into the service from an external food preparation company and then cooked at St Marys Haven. Cakes and snacks were prepared from scratch at the service. The meals looked appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.
People had access to activities. Activity co-ordinators were in post and arranged activities for people seven days a week. People had limited access to the local community as the service did not have a suitable vehicle of their own currently available. The provider was arranging for the hire of suitable vehicles are required for specific trips. School children visited the service regularly. We received feedback from this school. Comments included, “My class thoroughly enjoy going to meet up with their ‘elderly friends’ and I feel that both the children and the residents have benefitted from our visits. I love seeing the children interact with the residents” and “We will be returning on the 12th December to sing some Christmas tunes for the residents and they have promised they will sing some of their favourite Christmas songs for us in return. I cannot speak more highly about the home.”
The use of technology used to help improve the delivery of effective care was limited. Pressure mats were used to alert staff if people, who had been assessed as at risk of falls, were moving around. Call bells were provided to people in their bedrooms.
People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance. Mandatory training was provided to staff with regular updates provided. The registered manager had a record which provided them with an overview of staff training needs.
People's rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were understood and applied correctly. However, some authorisations which had been granted had not been notified to the CQC in line with legal requirements. This was addressed at the time of the inspection.
There were effective quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly by both the registered manager and a member of the senior management team. However, some of these audits had failed to identify the concerns found at this inspection.
We found a breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.