Background to this inspection
Updated
9 August 2023
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
The inspection team consisted of 2 inspectors. An expert by experience contacted the representatives of people living in the home by telephone. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
St Mary's Nursing Home 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 Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a manager in post working for healthcare management company. They were in the process of applying for registration with the Commission.
Notice of inspection
This inspection was unannounced.
What we did before the 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. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this to plan the inspection.
During the inspection
During the inspection we spoke with the manager, the deputy manager, and the area manager. We spoke with 2 nurses, 2 activities coordinators and 3 care workers. We also spoke with 3 people living at the home and 11 relatives by telephone. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed a range of records including 3 peoples care records, 6 medication records, 3 recruitment records of newly recruited staff as well as complaints, quality assurance records and records relating to accidents, incidents and safeguarding's.
Updated
9 August 2023
St Mary's Nursing Home is a care home providing nursing care for up to 74 younger and older people, people living with dementia and mental health needs and people living with a physical disability or sensory impairment. At the time of the inspection, there were 37 people living at the home.
St Mary's Nursing home is an adapted building which specialises in residential and nursing care. There are three floors named St Mary's, St Alexius and St Josephs.
People’s experience of using this service and what we found
St Mary's Nursing Home is operated by Qualia Care Limited. Qualia Care Limited has been placed into administration and the administrators have appointed a healthcare management company to operate the care home during the period of administration. The provider, Qualia Care Limited remains legally responsible for the delivery of the regulated activities at this location.
There had been improvements to health and safety of the home. Ongoing work was being undertaken to ensure the improvements both in the building and in the care provided were sustained and continually improved. Any risks to people were identified and mitigation guidance provided for staff to follow.
Care plans and risk assessments captured peoples’ care requirements and gave guidance for staff to support each individual safely. We made a recommendation for families to be involved in reviewing care records to ensure they were accurate. Complaints were acknowledged and responded to. Relatives felt confident to raise any concerns they had with the management team.
People felt safe living at the home. Relatives confirmed staff safely cared for their relation and staff were kind and caring. Staffing levels were sufficient to meet the needs of people currently living at the home. Staff were recruited safely and felt supported by the management team. Staff were confident in recognising and reporting any safeguarding concerns they may have. Medicines were safely managed.
People, relatives and staff felt the management team were approachable and responsive and had improved the home. The manager was working with other professionals to embed and sustain quality improvements. Staff were continually updated with any changes to people’s health and well-being and about the management of the home.
A manager was in post. The manager was working for healthcare management company and was in the process of applying for registration with the Care Quality Commission (CQC).
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.
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 focused inspection of this service was rated good (published 18 April 2023).
Why we inspected
The inspection was prompted in part due to concerns received about the management of complaints, staffing levels and visiting arrangements. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe, responsive and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Mary's Nursing Home 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.