St Mary's Nursing Home Margaret Street Stone

Updated 16 February 2024

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.

Inspection team

The inspection was carried out by 2 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 Margaret Street Stone is a ‘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. St Mary's Nursing Home Margaret Street Stone is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

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

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 (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 spoke with 10 people who used the service and 6 relatives. We spoke with 10 staff, including care staff and senior care staff, other support staff (such as activities and reception), the finance and administrator manager, the deputy manager and registered manager. We made observations in communal areas to find out people’s experience of care. We also contacted external professionals after their details were shared with us by the home.

We reviewed 6 people’s care plans and care records and multiple medicine records. We reviewed 3 staff files to check they were safely recruited. We looked at management records, such as audits and policies and procedures.

Updated 16 February 2024

About the service

St Mary's Nursing Home Margaret Street Stone is a care home providing personal and nursing care to older people. The service can support up to 59 people in one building over 3 floors. At the time of the inspection, the service was supporting 50 people.

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

Environmental risks to people had not always been mitigated enough to make sure people would always be protected. This included hot radiators and pipes and windows without appropriate restrictors on. There were some omissions in the information about ‘when required’ medicines and some gaps in recording, however no one had come to harm as a result of this. Quality assurance systems in place had failed to fully recognise and address risks to some people. Following feedback, all concerns were swiftly rectified by the registered manager and management team. Overall, medicines were managed safely, and people received these as prescribed.

People and relatives consistently felt safe living in the home and felt positive about the care they received. Staff knew people well. Staff understood their safeguarding responsibilities and how to recognise potential abuse. Staff were safely recruited to ensure they were appropriate to support those using the service. There were enough staff to keep people safe. The home was clean and tidy and without malodours. People and relatives confirmed this was consistently the case. There were no restrictions on visiting. Lessons were learned when things had gone wrong, with reviews taking place and an analysis of incidents to determine if there were any trends or further action needed.

People, relatives, and staff were consistently complimentary about the service, the registered manager and management team. The culture of the home was open and inclusive. People felt well cared for and all felt they could raise concerns if they needed to and felt confident these would be addressed. People were supported to practise their faith if they wished to do so. Staff felt equally well supported and there were extra support mechanisms in place. Learning was encouraged and shared, with staff empowered to be champions of areas they were passionate about. The registered manager was proactive and involved in many external organisations and schemes in order to continuously improve. Professionals confirmed the home worked in partnership. The registered manager was fully aware of their duty of candour.

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.

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 10 January 2022).

Why we inspected

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident was subject to further investigation by the CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of moving and handling. This inspection examined those risks.

We found no evidence during this inspection that people were at risk of harm from this concern. However, we found some environmental concerns. Please see the safe section of this full report.

Following the inspection, the CQC determined they would take no further action taken in response to the incident.

Enforcement

We have identified a breach in relation to quality assurance systems in place failing to identify and address environmental risks to people.

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