Archived: St Mary's Care Home

St Mary’s Care Home is a care home providing personal care to a maximum of 44 older people. At the time of our visit there were 18 people using the service.

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

Improvements had been made to ensure that risk assessments were clear and included how risks were to be mitigated.

The environment was safe and checks were carried out to identify any areas for action. There were appropriate infection, prevention and control procedures in place and staff were following these.

Medicines were managed and administered safely, and in line with the instructions of the prescriber.

Sufficient numbers of staff were deployed to ensure people were provided with support when they needed it.

Improvements had been made to the quality assurance system in place and areas for action were identified and acted upon.

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 ‘Inadequate’ (Report published 19 February 2021)

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.

This service has been in Special Measures since 19 February 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was planned to check whether the service had made the necessary improvements identified at the previous 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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

St Mary’s Care Home is a residential care home providing personal care for up to 44 older people living with dementia. At the time of our inspection, 27 people were using the service. The home is purpose built and all accommodation is on one floor.

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

We found the provider had made improvements in most areas of the service we looked at during this inspection however the provider is still in breach of regulations and continued improvement is required.

Whilst the service had reported safeguarding incidents to the local authority and understood the associated policies and procedures, they had not reported these, and other notifiable safety incidents, to the Care Quality Commission (CQC) as required by law. This is a continued breach.

Following our last inspection in August 2020, we requested an urgent action plan from the provider detailing what action the provider would be taking and by when to improve the service people received. These actions were followed up at this inspection and whilst the provider’s action plan had driven improvements in most areas we looked at, some actions had not been completed as stated and/or within the timeframes given.

Assessments of risk to people who had drug allergies and sensitivities had not been completed as stated in the provider’s action plan. This was of concern given that an incident had previously occurred within the service where a person who used the service had been given a medicine they were allergic to. Some improvements had been made to the management of medicines however concerns remained

We saw improvements in infection prevention and control (IPC) systems although further embedding and development was required. We saw that government guidance was being followed. However, staff did not always adhere to social distancing which increased the risk to people. Additionally, the service had failed to consider that actions may be needed to reduce the risks associated with COVID-19 in those people who used the service, and staff, who were disproportionally at risk of the virus.

Governance systems were in place to drive improvement although some of these had been sporadic in completion and had not fully identified issues. The completion of care documentation had improved but further improvements was required.

The people who used the service, their relatives and staff all told us kind care was being delivered and that improvements had been made since our last inspection, particularly around communication.

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 inadequate (report published 14 September 2020) and there were multiple breaches of regulation. The provider was also issued with a letter of intent to take urgent action due to concerns found. The provider completed a service improvement plan to show what they would do and by when to improve; we have followed this up at this inspection.

At this inspection although improvements were found, enough had not been made and the provider was still in breach of regulations. The provider needs to continue to make improvements regarding medicines and risk management, infection prevention and control, governance and ensuring procedures are in place to report notifiable safety incidents to CQC.

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about managing risk, reporting safety incidents to CQC and to assess the actions the provider told us they would take following our last inspection in August 2020. The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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 coronavirus 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 Care Home on our website at www.cqc.org.uk.

Enforcement

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. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risk management, governance and reporting safety incidents to CQC.

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.

Follow up

We will meet with the provider, and request an action plan, 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.

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

St Mary’s Care Home is a residential care home providing personal care to 31 people aged 65 and over, some living with dementia, at the time of the inspection. The service can support up to 44 people. It is a purpose-built home all on one floor.

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

People received care and support that was not consistently safe or appropriate. The risks they were exposed to had not been fully identified, assessed or mitigated. During a global pandemic, the provider had failed to train all their staff in infection prevention and control and ensure they used personal protective equipment (PPE) as per government guidance. The premises and equipment were unhygienic and visibly soiled. This put people at risk of infection, including COVID-19.

We could not be assured that people received care to keep them healthy and well. People had not received their medicines as prescribed and the monitoring of people’s health had been ineffective resulting in some people being exposed to harm and risk. We saw people had lost weight and did not receive the support they needed from staff to eat and drink.

Staff told us they had been scared to raise concerns or, if they had, their worries had not been actioned appropriately or promptly. This left people at risk. Staff had not received consistent support, training or had their competency checked; this left them feeling devalued and posed a risk to the people they supported. Communication was poor and relatives told us they had not been kept regularly informed about their family members, particularly during the pandemic lockdown when they needed extra reassurance.

The Care Quality Commission (CCQ) acknowledges that the current climate is one of global pandemic, and that providers have had to adapt their methods of oversight accordingly. However, the management within the service had been ineffective and the oversight from the provider had not been robust enough to promptly identify and rectify the concerns found at this inspection. Quality monitoring systems that were in place to drive improvement had failed and the lack of provider oversight compounded this. During our inspection we found staff lacked direction resulting in a chaotic approach.

The provider had installed a senior management team in the home as a result of the concerns raised prior to the inspection and had the support of other health and social care professionals, yet whilst some improvements were being made, we found the quality of the service was still poor. Regulatory requirements had not been met and we found the provider to be uncooperative during this inspection, failing to meet deadlines and providing information fully or promptly.

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 23 July 2018).

Why we inspected

We received multiple concerns in relation to medicines management, the premises, risk management, infection prevention and control and governance. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the seriousness of findings at this inspection.

We have found evidence that the provider needs to make significant improvement. 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 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.

Enforcement

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.

At this inspection, we have identified breaches of regulation in relation to safe care and treatment, safeguarding people from the risk of abuse, governance and notifying CQC of reportable events.

Please see the action we have told the provider to take at the end of this report.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety and we will meet with them on a monthly basis to discuss their plans. We will work alongside the provider and local authority to monitor progress.

St Marys Care Home was last inspected in September and October 2017 and was rated as Requires Improvement. We rated the key question of ‘Well led’ as Inadequate. At that inspection, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action to impose positive conditions. This meant the provider had to submit records to the Care Quality Commission (CQC), monthly, to demonstrate they were taking actions to rectify and improve the quality of care at the service. The CQC had already issued a warning notice, and placed a condition to restrict admissions to the service at a previous inspection in February 2017. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well Led to at least Good.

St Mary’s 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. St Mary’s Care Home provides personal care for up to 44 people over one floor. At the time of our inspection, there were 21 people living there. St Mary’s provides personal care to people living with a range of health conditions, including physical disabilities and people living with dementia.

At this inspection we found improvements had been made in all the areas identified at the previous inspection. This meant the service had met all the outstanding legal requirements from the last inspection and is now rated as Good. The key question of Safe continues to be rated as Requires Improvement as although we found improvements had been made, there were still shortfalls in the safe management of medicines.

There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff knew how to keep people safe from abuse. Staff were confident that if they had any concerns they would be addressed quickly by the registered manager. Risks to people had been assessed and regularly reviewed. Actions had been taken to mitigate these where necessary. Checks had been made on the environment to ensure the service was safe. Equipment to support people with their mobility, such as hoists had been checked to ensure people were safe.

The management of people’s medicines had improved, however, audits carried out by staff and by the providers quality assurance team had not identified errors in these records. Records of when people had topical medicines applied were not always completed.

There were enough staff to ensure people were safe and had their needs met in a timely way. Staff had the skills and knowledge to carry out their roles and were supported by a system of induction, relevant training, one-to-one supervision and appraisals.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. Staff understood their responsibilities under MCA, people's capacity had been assessed and when required best interest’s meetings had been held and recorded.

People told us that they enjoyed the food. People had a choice of meals and were supported to maintain a healthy diet in line with their choices, preferences and any healthcare needs. People's health was assessed and monitored. Staff took prompt action when they noticed any changes or decline in health. Staff worked closely with health professionals and followed guidance given to them to ensure people received safe and effective care.

Staff encouraged people to make decisions about their day-to-day care and remain as independent as possible. People's dignity and privacy was maintained by staff. People told us staff were kind and caring. Staff maintained people's dignity and encouraged choice. Staff supported people to maintain friendships and relationships. People's friends and family could visit when they wanted with no restriction to this.

There was a programme of activities available for people to enjoy. Care records were personalised to the individual and detailed how people wished to be supported. They provided clear information to enable staff to provide appropriate and effective care and support. Risks were clearly identified and included guidance for staff on the actions they should take to minimise any risk of harm.

Information about how to complain was on display in the service. People and relatives knew how to complain and were confident that any concerns they had would be listened to and acted on.

Audits were in place to monitor the quality of the service people received but did not always identify when improvements needed to be made. The registered manager reviewed the recorded accident and incidents. These were analysed to identify any patterns or trends and plans were put in place to reduce the risk of them happening again in the future.

People and their relatives were able to complete surveys to enable them to voice their opinions of the service and these were acted on. Staff and relative’s meetings were held regularly. Staff told us that they felt supported by the registered manager and that the service was a good place to work.

Services that provide health and social care to people are required to inform the CQC of important events that happen in the service. CQC check that appropriate action had been taken. The registered manager had submitted notifications to CQC in an appropriate and timely manner in line with CQC guidelines.

St Mary’s Care Home provides residential care for up to 44 people, some of whom may be living with dementia. At the time of this inspection there were 34 people living in the home.

Accommodation is over one floor and the home has a number of communal areas available to those living there as well as an accessible garden.

Whilst there was a manager registered with the Care Quality Commission (CQC) to manage this service at the time of this inspection, they were no longer working at the home. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was also no deputy manager in post at the time of this inspection and, on our first inspection visit, a senior care assistant was managing the home. An interim manager was in situ at our second inspection visit.

We last inspected this service in February 2017 where we found the provider had failed to meet the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At the February 2017 inspection, we found three breaches to the regulations. These breaches related to safe care and treatment, the need for consent and good governance.

We served requirement notices in relation to the need for consent and good governance. The provider sent us a plan to tell us about the actions they were going to take to rectify these breaches. They told us these would be completed by May 2017. In response to the breach to safe care and treatment, we took enforcement action against the provider in order to help drive improvement. We imposed conditions on their registration in relation to the management of medicines. This meant the provider had to submit records to the CQC, on a monthly basis, to demonstrate they were taking actions to rectify and improve medicines management. These had been submitted as required.

At this inspection, carried out in September and October 2017, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service continued to be in breach of safe care and treatment and good governance. In addition, the service had failed to safeguard people from abuse and improper treatment, to employ fit and proper persons and notify the CQC of reportable events that affect people’s safety.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The provider had failed to have effective systems in place to ensure a consistently caring, effective and safe service had been delivered. This failure had been evident since the provider first breached regulations to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in September 2014. The provider has been consistently non-compliant since this date and continues to be so.

On our first inspection visit, there was no management team in place to manage the day to day running of the service. The provider had placed the responsibility of this onto a senior care assistant who was also expected to work their normal role. This had put strain on the service particularly as the home was also working with less staff than the provider deemed appropriate to provide a service. At our second inspection visit, an interim manager was in place.

Full information and checks had not been sought on all employed staff in order for the provider to fully assess their suitability to work with those that used the service. This had put those who lived at the service at risk. Furthermore, the provider had failed to fully assess, analyse, manage and mitigate the individual risks to those living at St Mary’s Care Home. This had put them, and others, at risk of harm.

Incidents that had affected the safety of those using the service had not been reported to the local authority safeguarding team. The provider had also failed to report them to the CQC as required by law. This meant people were not fully protected and we could not be sure all preventable actions had been taken.

Care plans were not consistently accurate nor did they contain enough information in order for people to receive the care and treatment they needed. Whilst permanent staff knew the needs, preferences and likes of those that used the service, the service was using agency staff to fill gaps in the rotas. Not having enough accurate written information in relation to people’s needs put them at risk of not receiving the care they required.

Staff worked well as a team and the culture had improved. However, staff did not feel supported by the provider and were disheartened by the service’s unstable management history. They told us they were not consulted in relation to changes. Staff had, however, received training in order for them to meet the needs of those people who used the service.

Staff demonstrated a caring and kind approach and offered people choice. However, people’s dignity was not always maintained. Confidentiality was compromised at times.

Most people’s nutritional needs were met and they told us they enjoyed the food served. However, improvements were required in relation to the dining experience. We saw that dirty crockery remained in the dining room all morning and that information wasn’t readily available to people in regards to the food available.

People had mixed opinions in relation to the amount of stimulation and activities they received. Whilst most people enjoyed them, some felt there weren’t enough and that they lacked the opportunity to get out away from the home.

Access to a variety of healthcare professionals was available to people and we saw that prompt and appropriate referrals had been made as required. A GP delivered a weekly visit to the service and also provided treatment as required.

The risks associated with the building and environment had been identified and managed. Regular maintenance and servicing had taken place on equipment and checks were carried out as a preventative measure.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Improvements were identified in the service’s adherence to the MCA and people’s human rights were respected.

Improvements were also identified in relation to medicines management and administration although further development is still required.

St Mary’s Care Home provides residential care for up to 44 older people, some of whom may be living with dementia. The home is purpose built and accommodation is on one floor. All rooms, except four, have en-suite facilities. Communal areas include a number of lounges, a dining room and a conservatory. The home has extensive gardens. At the time of our inspection there were 28 people living within the home.

There was a registered manager in post whose application had been processed shortly before the inspection was carried out. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We inspected this service in April 2016 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Three breaches of legal requirements were found and a warning notice was issued in relation to one of them which involved the governance of the service. The provider sent us a plan to tell us about the actions they were going to take to meet the breaches of the remaining two regulations.

A further inspection was carried out in September 2016. This was a focused inspection to check that the service had undertaken changes to meet the warning notice. We found that sufficient improvements had not been made and that the service was still in breach of the regulation.

At this inspection in February 2017, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to safe care and treatment, the need for consent and good governance. Whilst some improvements had been made, the service continued to be in breach of the regulation relating to safe care and treatment for a third consecutive inspection. The service also continued to be in breach of the regulation involving the governance of the home for the fourth consecutive inspection.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Fully effective systems were not in place to monitor the quality of the service and drive prompt and continued improvement. The system had failed to fully identify and rectify the issues highlighted in this report.

The management and administration of people’s medicines did not fully follow good practice guidance. This meant that we could not be sure that people had received their medicines as the prescriber had intended.

The individual risks to the people who used the service had not always been identified, recorded or managed by the service. This was compounded by gaps in care records that did not effectively demonstrate that people had received the care and support they needed.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. People’s human rights had not always been respected and the service had not consistently worked within the principles of the Act. Staff were able to demonstrate that they assisted people to make choices but their knowledge of the MCA was poor.

The service had procedures in place that reduced the risk of employing people not suitable to work in the service. New staff received an induction and all staff received ongoing training. Staff told us that they felt supported in their roles and a supervision plan was in place to ensure staff received these. The registered manager also had a plan in place to complete staff appraisals.

At past inspections, there had not been enough staff to meet people’s needs. At this inspection, improvements had been made to staff deployment and their ability to meet people’s needs in a more prompt and appropriate timescale. The people we spoke with agreed. In addition, the service had undertaken regular monitoring to ensure call bells were answered in a timely manner and taken action where necessary to identify and rectify issues.

People received care and support in a respectful and dignified manner. Staff demonstrated kindness and warmth. People’s dignity, privacy and confidentiality were maintained and choice was supported. Staff knew the likes, dislikes and preferences of the people who used the service.

Staff had received training in safeguarding people and the service had procedures in place to help reduce the risk of abuse. Accidents and incidents were monitored in order to reduce the risk of reoccurrence. The risks associated with the building, adverse incidents and working practices had been identified and appropriately managed.

People told us that their needs were met and they had been involved in their plan of care. Care plans had been regularly reviewed, were accurate and person centred. However, the quality of care plans varied. Some did not contain enough relevant information to fully reduce the risk of people not receiving the care and support they required.

Improvements had been made in the provision of social and leisure activities and people enjoyed these. More activities were on offer and we saw that people were fully engaged in these.

People’s healthcare needs were met and the healthcare professionals we spoke with were complimentary about this aspect of the service. Recommendations were followed and people had access to a wide variety of healthcare provision.

People’s nutritional needs were met and they had enough to eat and drink. Where people required specialist diets, these were provided and understood by staff. People were offered choice in what they had to eat and drink. However, not all people received the assistance they required at a time they needed it in relation to assistance with eating and drinking.

A number of systems were in place to capture people’s feedback on the service and where concerns had been raised, these had been actioned. A number of feedback documents had recorded recent improvements to the service. People told us that they were satisfied in how the service had managed complaints but the records around the management of these were varied.

A new management team were in post and people spoke positively about their abilities and proactive approach. They told us the management team were visible, helpful and approachable.

We undertook this focused inspection to check that the service had undertaken changes to meet the legal requirements of this regulation. This report only covers the findings in relation to the warning notice. You can read the report from our last comprehensive inspection in April 2016, by selecting the 'all reports' link for St Mary’s Care Home on our website at www.cqc.org.uk.

At this inspection carried out on 1 September 2016 we found that there were still considerable concerns in relation to the governance of the home. We have not changed the overall rating for this service as a result of this inspection as it was only undertaken to follow up our enforcement action. The service, and the domain of well-led, remains as requires improvement.

St Mary’s Care Home provides residential care for up to 44 people, some of whom may be living with dementia. At the time of our inspection 36 people were living there. Accommodation is on one floor with a number of communal areas.

At the time of this inspection, the home did not have a registered manager in post and a number of recent changes had occurred in the management of it. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager had left at the end of July 2016 and an interim manager had been in post. This person had also recently left the service and an acting manager had been appointed the week prior to our inspection. The acting manager had been employed by the provider for approximately five weeks having been originally appointed as a deputy manager at St Mary’s Care Home. During our visit, two registered managers from other homes owned by the provider were present to support the acting manager during the inspection.

At this visit carried out on 1 September 2016 the managers we spoke with could not provide us with all the information we requested. We therefore gave the provider the opportunity to submit any further information in relation to the warning notice up until 5pm the following day. No additional information was submitted.

At the inspection in April 2016, concerns were identified that demonstrated that the provider did not have effective systems in place to monitor the quality and safety of the service delivered. This had resulted in some people receiving a poor service.

At this inspection we saw that although some improvements had been made, the service was still in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which relates to governance.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Although some processes were in place to monitor the quality and safety of the service provided, these were not wholly effective. The service had failed to appropriately manage the concerns highlighted in this report. These included a lack of staff to meet people’s needs in a person-centred manner resulting in people having to wait for assistance. Issues in relation to medicines administration and management had not been identified by the service. There was also a lack of clear action plans when it had been identified that the service fell short of the required standard.

Some improvements had been made since our last inspection in April 2016. The service had identified some issues that were contributing to staff shortages and had introduced measures to address this. In addition, more consistent and comprehensive recording of people’s medicines and their administration was noted. Senior staff told us that they had received training in medicines administration and that their competency to do so had been audited and assessed. Additional support had been received by senior staff in relation to their role and in medicines administration. Medicines, particularly topical medicines, were securely stored which had mitigated the risk of potential ingestion and misuse by the people who used the service.

St Mary’s Care Home provides residential care for up to 44 people, some of whom may be living with dementia. Accommodation is on one floor and all rooms, except four, have en-suite facilities. Communal areas include a number of lounges, a dining room, conservatory and extensive gardens. At the time of our inspection, 35 people were living in the home.

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

We last inspected this service on 12 and 17 November 2015 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of four regulations relating to safe care and treatment, meeting nutritional and hydration needs, staffing and good governance.

Following the inspection in November 2015, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations. They told us these actions would be completed immediately.

At this inspection in April 2016, we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to staffing levels, medicines management and governance. You can see what action we told the provider to take at the back of the full version of this report.

Although the service had a system in place to monitor and assess the quality of the service, these had not been effective as they had not fully identified the issues highlighted in this report.

The medicine records contained gaps and inconsistencies and so it was not clear whether people had received their medicines as the prescriber had intended. Medicines for external application were not securely stored meaning these could be accessed which put people at potential risk.

People‘s individual needs were not always met in a timely manner and people told us there were not enough staff. People sometimes had to wait for assistance. The service had not consistently provided the amount of staff they had assessed as being required to meet people’s needs.

Staff did not always promote people’s dignity and their independence was not always maintained. However, people had choice in how they spent their day and staff treated them with respect. Staff demonstrated a kind and caring approach when supporting people.

Training had been provided to ensure staff were competent in their roles. Staff told us they received regular support and were encouraged to offer suggestions for improving the quality of the service. However, some staff did not always feel that the service managers listened to them.

People were encouraged to provide feedback on the service and complaints were investigated. However, some people did not feel that their complaints had been listened to appropriately and did not feel confident that it would be addressed effectively. The registered manager had acknowledged this and sought training to improve their skills in this area.

The risks to people, visitors and staff had been identified, assessed and reviewed on a regular basis. Staff understood the processes in place to help protect people from the risk of abuse and knew how to report any concerns they may have. Accidents and incidents had been recorded, fully investigated and actions taken to minimise any future risk of reoccurrence. Recruitment processes were in place to ensure that the risks of employing unsuitable staff were minimised.

People, and where appropriate, their relatives, had been involved in planning the care they received. Care records showed that these were individual to the person and took their views fully into account. Staff demonstrated that they knew the people they supported including their likes, dislikes and preferences.

The principles of the Mental Capacity Act 2005 and associated legislation had been adhered to. The service had assessed people’s capacity to make decisions as required and involved others in making best interests decisions where applicable.

People received enough to eat and drink and any specialist diets were catered for. A range of healthcare professionals were available to assist the service in meeting people’s health and wellbeing needs and activities were provided.

This inspection was carried out in response to concerns raised with us about low staff numbers at night. We were also told that people were being got up early in the morning whether they wanted to or not. As a result, this inspection commenced at 5:45 a.m. in the morning and was unannounced.

The inspection team who carried out this inspection consisted of two inspectors. The focus of the inspection was to answer four key questions: Is the service safe? Is the service effective? Is the service caring? Is the service responsive to people's needs?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We looked at the staff rotas which showed there were not always sufficient staff on duty to meet people's needs throughout the day and night. They showed that over the four weeks prior to our visit, there had been 15 occasions when the home was staffed below the level the service deemed necessary overnight. The rotas for during the day also showed that the service was staffed below the level the service deemed necessary on 25 shifts. This meant that people did not receive a consistent and safe level of support.

One person told us, 'You ring the bell at lunchtime and you have to wait 20 minutes or half an hour.' Another person said, 'Most of the staff are good but there's not enough of them.' A visitor commented, 'I've told them there's not enough staff but they told me they were fully staffed.'

We spoke with the manager about the Deprivation of Liberty Safeguards (DoLS). They told us that they had been in contact with the local authority to enquire about when they could commence making applications. This demonstrated to us that where there were concerns that the appropriate action would be taken.

Is the service effective?

People had an individual care plan which set out their care needs. The care plans we looked at recorded that relatives had been involved in the review process although they had not signed the review forms to demonstrate they agreed with the plans. Night care plans, setting out how people wished to be cared for at night were not in place.

Staff explained how they offered choices to people around the time they got up in the morning and the clothes they wore. Where people were unable to make these choices, staff told us they acted in the best interests of the individual or in accordance with the manager's instructions. However, we did not find evidence that staff had followed the guidelines of the Mental Capacity Act 2005 in making decisions for these people.

Is the service caring?

People we spoke with told us that most of the staff were good and treated them with care and consideration. Some visitors told us, 'We're satisfied with the care [person] receives.' People appeared well cared for and relaxed.

We observed the interaction between staff and people using the service and their visitors. We saw that staff were polite, respectful and friendly. Plenty of laughter was heard at the pre-lunchtime quiz.

Is the service responsive to people's needs?

People told us that they often had to wait for help and support from staff. One person described how it often took staff 20 minutes to half an hour for staff to respond to their call bell. Visitors also spoke about waiting long periods for staff to respond when they rang the bell on behalf of their relative. During our visit we were aware that call bells were ringing almost continuously from the time of our arrival until just before lunchtime.

We reviewed the evidence we had obtained during our inspection and used this to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well lead?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

People told us they felt safe and that they were treated with respect by staff. The service was clean and hygienic and there was a cleaning schedule in place to keep the home fresh. One person told us, "It's all very good and I really do mean that."

There were sufficient numbers of qualified, skilled and experienced staff on duty. Staff training was up to date and was relevant to the needs of the people living at St Mary's. This helped to ensure that people's needs were met.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

Is the service effective?

The service was introducing new care plan documents and these showed that people's health care needs were assessed. Health and risk assessments identified individual care needs. People told us they were supported to be as independent as possible. One person said, "Staff help me to get up in the morning, then I see to myself."

Visitors told us they could see their relative whenever they wished and that staff always made them welcome. One visitor spoke about how their relative had told a member of staff they felt hungry and the member of staff had brought them some food to eat to see them through until the next mealtime.

Is the service caring?

People told us they liked living at St Mary's and that staff were kind and caring. One person told us, "The staff are kind and attentive." Another person said, "They treat me with respect and speak to me nicely." A visitor to the home told us, "I can't fault them. Just ask and they'll do."

People were supported by kind and attentive staff. We saw that care workers were warm, friendly and respectful and that they offered choices and encouragement to people. Staff had received training that was relevant to their role.

People told us they could spend their day where and with whom they pleased and staff assisted them to do this. One person spoke about preferring to spend time in their room although they had enjoyed attending an activity during the morning.

Is the service responsive?

People were able to access a variety of activities at the service. These included group and one-to-one activities and also outside entertainments. Staff understood the diverse needs and preferences of the people living at the home and how they could be met. Residents' and relatives' meetings were held regularly to seek the views of people using the service.

People knew how to make a complaint if they were unhappy. The complaints process was displayed in the entrance hall. People and visitors were asked to complete annual questionnaires about the quality of the service. The results of these questionnaires were used to develop an action plan for improvement.

People's needs were assessed with reviews taking place on a monthly basis. Where changes occurred the service referred to health professionals for advice and guidance whenever necessary. A visiting health professional confirmed that the service referred to them appropriately and in a timely way.

Is the service well lead?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

Staff told us they were clear about their roles and responsibilities. They had a good understanding of the ethos of the home, although there was some uncertainty due to the absence of the registered manager.

The service had a quality audit system in place and records seen by us showed that identified shortfalls were addressed. As a result, the quality of the service was continually improving. Audits of the environment were taking place regularly and these records were up-to-date and showed remedial action had been taken where shortfalls were identified.

One person we spoke with had just finished having lunch in their room, which they said was where they preferred to have it. This person also smiled and nodded when we asked if they had enjoyed their lunch that day.

We noted significant improvements to the atmosphere, environment and care provision in St Mary's since our previous inspection in January 2013. Overall, we noticed that there were more people choosing to spend time in various communal areas during this inspection and the whole atmosphere was relaxed, calm and cheerful.

We noted various feedback from people living in the home, expressing their pleasure with some of the environmental improvements, with comments such as: "'love the new hairdressing room and the hairdresser!"

However, one person we spoke with said that the staff were very good and another person showed us that they had just had their nails polished by a member of staff, which they said they were very pleased with.

We met and spoke with a person who had recently moved into the home and a family member. Both people said they were very impressed by the food, especially the home-made sponge. The person who had recently moved in told us that they were, "Very happy and settling in well". They also said that the manager and staff were very friendly and helpful.

The person's relative told us that they lived locally and had never heard a bad word spoken about St Mary's. They went on to say that they had been instantly impressed when they came to look around and that the staff had taken time to get to know their relative's needs and preferences.

We gathered further evidence of people's experiences of the service by carrying out observations and reviewing the information contained in care records.

The majority of our observations showed staff treating people with respect and speaking to them in a friendly manner. However, we saw that, particularly for people with higher levels of need and limited communication, staff sometimes carried out tasks and provided support with little to no interaction.