Archived: St Mary's Haven & St Mary's Haven Respite

Updated 15 December 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 30 October and 2 November 2017.The inspection was carried out by one adult social care 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. Their area of expertise was in older people’s care.

Before the inspection we reviewed information held by CQC about the service such as notifications. A notification is information about important events which the service is required to send to us by law.

We spoke with the provider, operations manager, a registered manager from another service owned by the provider, the hospitality manager and six staff members on duty. We spoke with ten of the people using the service and four relatives. We also received feedback from an external professional during the inspection.

We spent time observing care practices and interactions between staff and people using the service. We looked at care documentation for four people living at St Mary's Haven & St Mary's Haven Respite and medicines records for 20 people, four staff files, training records and other records relating to the management of the service. In addition we checked the building to ensure it was clean and a safe place for people to live.

Updated 15 December 2017

This unannounced comprehensive inspection took place on 30 October and 2 November 2017. This was the first rateable inspection for the service since registration in September 2016.

St Mary's Haven & St Mary's Haven Respite is a care home which offers care and support for up to 34 predominantly older people. At the time of the inspection there were 34 people living at the service. Some of these people were living with dementia. The service uses a detached house over two floors with a lift to provide access to the upper floor.

The service did not have a registered manager in post; a new registered manager was due to begin working at the service the week after the inspection took 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.

Medicine administration processes were not robust. For example, Medicine Administration Records (MAR) did not record when creams were applied. We saw instances where a medicine had been hand transcribed onto the MAR. These were not double signed. It is safe practice for one person to witness this being carried out to ensure accuracy. One person’s MAR recorded a change in dose of their medicine; there was no apparent authorisation on the records to account for this change. Transdermal patches were not routinely recorded on body maps to demonstrate where they had been placed. This meant it was unclear where patches had been situated when they required rotating to a different place. We saw overstocking of one controlled drug. Regular medicine audits were carried out. However, these had failed to identify the issues we identified.

The service had not employed the use of a needs based staffing tool to assess the number of staff employed to meet people’s needs. We observed and rotas evidenced there were adequate numbers of staff available throughout the day to meet people’s needs. However, there was some concern about whether there were enough staff available overnight. We have made a recommendation about this.

Care plans recorded risks that had been identified in relation to people’s care and these were appropriately managed. People’s risk assessments had been regularly updated so staff knew the best way to care for people taking into account their changing safety needs. A professional who worked with the service told us, “I don’t have any concerns.”

Staff knew how to recognise and report the signs of abuse and had access to, and understood the service’s safeguarding and whistle blowing policies.

Recruitment processes were robust. All appropriate pre-employment checks were completed before new employees began work.

The premises were largely well maintained, clean and free from malodours. Some areas were due for redecoration and management told us about plans to refurbish and extensively develop the service in the New Year.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. People were treated with kindness, compassion and respect.

Systems for monitoring staff induction, training and supervision were not effective.

People had access to a varied and nutritious diet. For people who did not enjoy the style of meals on offer, alternatives were not variable enough to meet their personal preferences.

The management had a clear understanding of the Mental Capacity Act 2005 and how to make sure people who did not have the mental capacity to makes decisions for themselves had their legal rights protected.

Staff were kind and compassionate and treated people with dignity and respect. Staff respected people’s wishes and provided care and support in line with those wishes. People were able to make day to day decisions about how and where they spent their time.

People received personalised care and support which was responsive to their changing needs. Staff supported people to take part in social activities of their choice.

People and their families told us if they had a complaint they would be happy to speak with the designated manager and were confident they would be listened to.

Systems for ensuring appropriate quality assurance in areas such as supervision, training and medicines audits were not effective.

The provider had not ensured the privacy and safety of archived personal records.

There was a breach of the regulations found at this inspection. You can see the action we have told the provider to take at the end of this report.