St Mary's House

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.

St Mary’s House is a residential care home providing personal and nursing 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 25 people using the service.

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

Systems to monitor and assess the quality of the service were not robust. The provider had not identified all of the issues we found on this inspection. We found a number of concerns regarding the health and safety aspects of the building.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The care people received met their needs. A relative said, “The home from the outside looks like a dump, but inside it’s a wonderful colourful home. People with dementia love colour.”

People received their medicines as prescribed.

There were sufficient staff to keep people safe and meet their needs.

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 good (published 2 December 2017).

Why we inspected

This inspection was prompted by a review of the information we held about this service and concerns raised by the fire service. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of the full report. You can see what action we have asked the provider to take at the end of the full report. Since the inspection we have received assurances that the provider has taken action to mitigate the risks identified

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 changed from Good to Requires Improvement. This is based on the findings at this inspection.

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.

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 monitor the service and will take further action if needed.

We have identified breaches in relation to the safety of service users and the overall management of the service.

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 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.

St Mary’s House 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 House accommodates 28 people in one adapted building. It is a care home for older people some living with dementia.

A registered manager was in place. 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.

Staff knew how to respond to possible abuse and how to reduce risks to people. Risks to people from receiving care and support were appropriately assessed and managed. There were enough staff to meet people’s assessed care and support needs. Staff had been recruited properly to make sure they were suitable to work in this environment. Medicines were stored and administered safely.

People were cared for by staff that had received the appropriate training and had the skills and support to carry out their roles. Staff members understood and complied with the principles of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People received a choice of meals, which they liked, and staff supported them to eat and drink enough. Where necessary people’s food and fluid intake and weight was monitored.

Staff were caring and kind and treated people and each other with respect. People were listened to and were involved in their care and what they did on a day to day basis. People's right to privacy was maintained by the actions and care given by staff members.

People's personal and health care needs were met and care records guided staff in how to do this. Activities in the service were limited. The management team were aware of this and were recruiting an activities co-ordinator to help make improvements. We have made a recommendation about activities for people living with dementia.

Complaints were investigated and responded to and people knew who to speak with if they had concerns.

Staff worked well together and felt supported by the management team. The monitoring process looked at systems throughout the home, identified issues and staff took the appropriate action to resolve these. The registered manager and provider were clear about how they were going to ensure the service continued to improve.

Further information is in the detailed findings below.