St Marys

Updated 22 February 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was a comprehensive inspection that took place on 15 January 2018 and was unannounced. The inspection team consisted of one inspector 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.

On this occasion we did not ask the provider to send us a Provider Information Return (PIR). This is a form that asks the provider information about the service, what the service does well and improvements they plan to make. However, we offered the provider the opportunity to share information they felt relevant with us.

The inspection was also informed by other information we had received from and about the service. This included previous inspection reports and statutory notifications. A notification is information about important events which the provider is required to send us by law. We also sought feedback from the local authority, who commission services from the provider and Healthwatch.

On the day of the inspection we spoke with eight people who used the service and two visiting relatives. We observed care and support in communal areas of the service and 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.

During the inspection we spoke with the registered manager, home manager, a senior care worker and two care staff and the housekeeper. We also spoke with two visiting community nurses. We looked at all or parts of the care records of four people, along with other records relevant to the running of the service. This included how people were supported with their medicines, quality assurance audits, training information for staff and recruitment and deployment of staff, meeting minutes, policies and procedures and arrangements for managing complaints.

Updated 22 February 2018

We inspected this service on 15 January 2018. The inspection was unannounced.

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

St Marys accommodates up to 23 older people including people living with dementia. On the day of our inspection 14 people were living permanently at the service and three people were receiving respite care.

The service had a registered manager at the time of our inspection. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the home’s previous inspection in January 2017 we identified one breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was in relation to Regulation 17 Good Governance. Systems in place to check on quality and safety were not as effective as they should have been. Following this inspection the registered provider was required to send us an action plan to inform us of the action they would take to make the required improvements.

During this inspection we checked to see whether improvements had been made, we found the breach in regulation had been met and all areas of the service had improved resulting in positive outcomes for people.

People were protected from potential abuse and avoidable harm because staff were aware of their role and responsibilities and had received safeguarding training that informed their practice. Risks in relation to people's needs including the environment were assessed, planned for and monitored.

Action had been taken to improve the internal environment, this included some refurbishment work, repairs and replacement of furnishings.

There were sufficient staff employed and deployed to support people. Safe staff recruitment practice was in place and followed. People received their prescribed medicines safely and these were managed appropriately. Protocols in place to advise staff of medicines prescribed to be taken as and when required were not consistently detailed.

People lived in a clean, hygienic service and there was a prevention and control of infections policy and procedure guidance to support staff. Staff supported people effectively during periods of anxiety that affected their mood and behaviour. Accidents and incidents were reported, monitored and reviewed to consider the action required to reduce further reoccurrence.

People were supported effectively by staff that knew and understood their individual needs. Staff received an appropriate induction, ongoing training and opportunities to discuss their work, training and development needs. New staff had not always received training in a timely manner but action was taken to immediately address this.

People's dietary needs had been assessed and planned for and they received a choice of meals and drinks. Systems were in place to share relevant information with other organisations to ensure people's needs were known and understood. People were supported to access healthcare services and their health needs had been assessed and were monitored. Staff worked well with external health care professionals in managing people’s health needs and outcomes.

People had choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice. The principles of the Mental Capacity Act (2005) were followed when decisions were made about people's care. Deprivation of Liberty Safeguards were in place for some people where required.

People were supported by staff who demonstrated a good understanding of their needs and were found to be caring and kind, showing empathy and compassionate in their approach. People's diverse needs were known and understood by staff and they were encouraged as fully as possible to be involved in discussions and decisions about their care and support. People were provided with information about how they could access independent advocates. There were no restrictions of when people's relatives could visit them.

People received a responsive service that met their individual needs, routines and preferences. Improvements had been made to the information to support staff to understand and meet people’s needs effectively. People were treated equally, without discrimination and systems were in place to support people who had communication needs. People received opportunities to participate in activities. People had access to the provider's complaint procedure that was provided in an appropriate format to support people's communication needs. People’s end of life wishes had been discussed and plans were in place.

Improvements had been made to the systems and processes in place to check on quality and safety. Staff were positive about the improvements made and were clear about their role and responsibilities. People who used the service, relatives and others were invited to give feedback about the service.