St Mary's Nursing Home

Updated 19 May 2022

The inspection

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 Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

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 Nursing Home is a residential care home. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

At the time of our inspection there was an experienced registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since. 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 (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spent time seeing how people were cared for by staff and spoke with four people and 11 relatives. We received feedback from nine members of staff including the registered manager, a nurse, the provider, the chef, housekeeping staff and care staff.

We reviewed a range of records. These included four people’s care records and multiple medication records. We looked at records relating to the management of the service and the safety and quality of people’s care. For example, audits and checks undertaken by the registered manager and provider. These included the safety of the premises and equipment, promotion of people’s rights, complaints management, accidents and incidents and infection control. We reviewed a range of policies and procedures relating to infection control, people’s safety and staff support.

We saw feedback provided by people and their relatives. In addition, we looked at records showing us how staff were recruited.

Updated 19 May 2022

About the service

St Mary's Nursing Home is a residential care home providing accommodation and nursing support to up to 56 people of all ages, some with a physical disability. The service provides care to people who require nursing support. At the time of our inspection there were 30 people using the service.

St Mary's Nursing Home accommodates people in one adapted building over two floors. The home had extensive gardens and outside spaces for people to enjoy.

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

People were supported by staff who understood what action to take if they had any concerns for their safety. Staff were provided with the guidance required so they could support people to manage their risks. There were enough staff to care for people and spend time chatting with them, so people did not feel isolated. The registered manager undertook checks before new staff worked at the home, so they could be assured new staff were suitable to work there. People were supported to have the medicines they needed by staff who had been trained to do this. The registered manager was improving medicine systems, so they could be assured staff consistently had the guidance they required to administer “when required” medicines. Systems were in place to reduce the likelihood of the spread of infections. The registered manager had worked with people and their visitors to ensure people continued to receive visits safely. Accidents and incidents were regularly reviewed so any lessons would be learnt.

People’s needs were assessed and informed through work with their relatives and other health and social care professionals. Relatives were complimentary about how staff used their skills and knowledge to support people. This included how staff monitored people’s health needs and advocated for them so they would enjoy the best health outcomes possible. Where staff had any concerns for people’s fluid or nutritional intake plans were developed to support them. 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.

Since our previous inspection the registered manager and provider had made improvements to systems and procedures to provide a good quality service. Relatives and staff told us the culture at the home was open and focused on the needs of the people living at the home. This helped to ensure people had good outcomes. The registered manager and provider undertook checks on the quality and safety of the care provided.

Rating at last inspection

The last rating for this service was requires improvement (published June 2019) and there was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the last inspection we required them to send us an action plan showing how they were meeting the requirements of regulation 17. At this inspection we found the provider had completed actions on their action plan, there was no longer a breach of regulation 17.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 20 May 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this focused inspection to check the provider 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 of safe, effective and well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. 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 Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.