Archived: St Mary's House

Updated 12 January 2015

We visited St Mary’s House on 31 July 2014. The inspection team consisted of one inspector, and an expert by experience. An expert by experience is a person who has experience of using or caring for someone who uses this type of service.

We reviewed previous inspection reports and the Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also looked at safeguarding concerns reported to CQC. This is where one or more person’s health, wellbeing or human rights may not have been properly protected and they may have suffered harm, abuse or neglect. This enabled us to ensure we were addressing potential areas of concern.

We spoke with three people who were able to express their views and five relatives. We spent time observing care in both dining rooms and used the Short Observational Framework for Inspectors (SOFI). This is a specific way of observing care to help us understand the experiences of people who were unable to talk with us, due to their complex health needs. 

We looked at records in relation to three people’s care. We spoke with three staff, the registered manager and provider. We also spoke with a GP and personal fitness trainer visiting the service. We looked at records relating to the management of the service, staff recruitment and training records, and a selection of the service’s policies and procedures.

This report was written during the testing phase of our new approach to regulating adult social care services. After this testing phase, inspection of consent to care and treatment, restraint, and practice under the Mental Capacity Act 2005 (MCA) was moved from the key question ‘Is the service safe?’ to ‘Is the service effective?

The ratings for this location were awarded in October 2014. They can be directly compared with any other service we have rated since then, including in relation to consent, restraint, and the MCA under the ‘Effective’ section. Our written findings in relation to these topics, however, can be read in the ‘Is the service safe’ sections of this report.

Updated 12 January 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

The service was last inspected on 09 October 2013 and at the time no breaches in regulations were identified. This was an unannounced inspection. St Mary’s House is a residential care home providing personal care for up to 28 older people, some of whom may have dementia. There were 27 people living at the service when we visited.

A registered manager was in post. A registered manager is a person who has registered with the CQC to manage the service and has the legal responsibility for meeting the requirements of the law, as does the provider. The registered manager was also the registered provider.

The Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) were not fully understood by staff and when these should be applied. These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals. These safeguards were not being consistently applied, and therefore it was not clear if people were being assessed to see if they had capacity to consent to their care and where required treatment. Neither was there any reference to DoLS and whether these should be applied so that people were protected from having their rights restricted inappropriately. The shortfalls we found breached regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and you can see what action we told the provider to take at the back of the full version of the report.

The provider had systems in place to protect people from abuse. People’s care plans contained individual assessments in which risks to their health, such as developing pressure ulcers and malnutrition, were being assessed and managed appropriately. Specific care plans had been developed where people displayed behaviour that was challenging to others. These provided guidance to staff so that they managed behaviour that was challenging in a consistent and positive way, which protected people’s dignity and rights.

Thorough recruitment process were in place that ensured staff had the right skills and experience and were safe to work with people who used the service. Staffing levels were based on the assessed needs of the people who used the service and this was kept under review. People who used the service, relatives and staff told us that there was enough staff available to meet people’s needs. Staff confirmed they received training and support which kept their knowledge up to date and gave them the skills, knowledge and confidence to carry out their duties and responsibilities effectively.

People and their relatives were complimentary about the staff and told us that they were caring at all times and respected their privacy and dignity. Staff were motivated and demonstrated that they knew people’s needs well. The interaction between staff and people was warm, caring and friendly.

People told us they were able to discuss their health needs with staff and had contact with the GP and other health professionals, as needed. Relatives told us staff were good at keeping them informed about their relative’s health and welfare. People were protected from the risks associated with eating and drinking. People spoke positively about the choice and quality of food available. Where people were at risk of malnutrition, referrals had been made to the dietician and speech and language team for specialist advice.

People, and those that mattered to them, were able to have a say on how they wanted their care and support provided. Information in three people’s care plans confirmed that their personal preference on how they wanted their care and support provided had been sought, and acted on. A customer satisfaction survey had been completed in October 2013 providing positive feedback about the service.

People we spoke with, including relatives, visiting professionals and staff praised the registered manager for their values, such as kindness, compassion and respect for people who used the service. Staff told us that the manager was very knowledgeable and inspired confidence in the staff team and led by example.

Systems were in place which continuously assessed and monitored the quality of the service, including obtaining feedback from people who used the service and their relatives. Systems for recording and managing complaints, safeguarding concerns and incidents and accidents were monitored and management took steps to learn from such events and put measures in place which meant they were less likely to happen again.

The registered manager and senior staff accessed local training initiatives and meetings to keep themselves up to date with new ways of working and changes in legislation. The provider was also a member of several good practice initiatives, such as Dignity in Care and the Dementia Pledge, working towards developing good quality care for people living with dementia.