St Mary's House

Updated 22 December 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

This inspection was carried out by one inspector.

Service and service type

St Mary’s House 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 House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

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 a registered manager in post.

This inspection was unannounced.

What we did before 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

On the day of the inspection visit we observed the care and support being provided in the communal areas of the service. This helped us understand the experience of people who could not talk with us. We spoke with the Registered Manager and toured the service. We spoke with one person living in the service and one relative. We also spoke with the registered manager, the deputy manager and four members of care staff.

We reviewed various documentation on the day of our inspection visit and the service supplied further documentation electronically following our visit. Documentation reviewed included three care plans and quality assurance documents.

Updated 22 December 2022

About the service

St Mary’s House is a residential care home providing personal care for to up to 28 people. The service provides support to older people and those living with dementia. At the time of our inspection there were 24 people using the service.

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

At our previous inspection we found the systems to monitor and assess the quality and safety of the service were not robust. At this inspection we found that improvements had been made and professional input had been sought. However, governance processes had not identified all the issues we found on this inspection and actions required to remedy the identified concerns had not yet been completed. The registered manager assured us that action was being taken to address all the concerns.

People were protected from the risk of abuse because the provider had effective safeguarding systems in place. People received their medicines as prescribed. There were enough staff to safely support people.

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.

Staff were caring and promoted people's independence. People were treated with dignity and respect. People were supported to take part in activities and belong to the community of the service.

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 requires improvement (published 26 July 2022) and there were breaches of regulation relating to safe care and treatment and governance. 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.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 26 July 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This inspection checked whether the provider had met the requirements of the Warning Notice in relation to Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on a concern we had about the safety of the building.

This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contained 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 remained requires improvement. 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 House 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.