St Mary's Nursing Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified a breach of regulations in relation to safe care and treatment under the key question of safe. People’s individual risks were not accurately recorded and not always managed safely. People and their relatives told us they felt safe in St Mary’s Nursing Home. There was limited evidence that audits of processes to keep people safe were effective. The new manager had introduced systems to review incidents and identify learning. These new processes need time to be embedded to improve the quality of care and support.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback from people who lived in St Mary’s Nursing Home. People told us they felt safe in St Mary’s Nursing Home. One person told us, “I feel safe and well cared for. [The staff] are nice with me and my room is nice and mostly cleaned each day.” Another person told us, “Sometimes they are short of staff. It is mostly short on a night or on a weekend. When I call for [the staff] it is usually half an hour before they come.” We spoke to family members and one person told us, “They do discuss [person’s] plan of care with me. I can call into the office at any time. [The staff] discuss [person’s] medication with me.” Our inspection found elements of care did not meet the expected standards of safety and person-centred care. Care records did not accurately reflect people’s care and support needs and there was a lack of person-centred care which meant people were not always treated as individuals.

The existing systems around learning from incidents were not effective. The manager demonstrated a commitment to developing a learning culture and had identified new systems and processes to make improvements.

There was limited review or analysis of incidents to identify learning and improvement for the staff and the service. The home was under a fire enforcement notice from South Yorkshire Fire and Rescue Service and we observed that changes and improvements were being made to ensure compliance and safety. The manager was committed to making identifying learning and making improvements but had not been in post for sufficient time to embed the necessary changes.

We spoke to family members and one person told us, “They do discuss [person’s] plan of care with me. I can call into the office at any time. [The staff] discuss [person’s] medication with me.” Our inspection found elements of care did not meet the expected standards of safety and person-centred care. Care records did not accurately reflect people’s care and support needs and there was a lack of person-centred care which meant people were not always treated as individuals.

The manager recognised the value and importance of working with partners to improve staff knowledge and understanding of local systems and how people transitioned through them. Staff had limited knowledge of the wider health and care systems and referral pathways.

Partners had identified areas for development and improvement in the service. Improvements were identified in clinical and service leadership and management. The provider attended regular meetings with partners to update on improvements and developments.

Systems and processes to monitor and review care pathways and transitions between care and services were not effective. The manager was taking action in response to this. Systems and processes to audit and review responses to call bells were not in place. The manager had contacted the call bell provider company to put in place a reporting system that would enable them to review call bell response times.

People told us they felt safe in St Mary’s Nursing Home. One person told us, “I feel safe and well cared for. [The staff] are nice with me and my room is nice and mostly cleaned each day.” Our inspection found elements of care did not meet the expected standards of safety and person-centred care. Care records did not accurately reflect people’s care and support needs and there was a lack of person-centred care which meant people were not always treated as individuals.

The manager demonstrated a commitment to safeguarding and understood the principles of keeping people safe. Appropriate notifications were made to CQC and referrals were made to the local Safeguarding Adults team.

We observed incidents where people were not safe and staff did not act appropriately to keep them safe. We asked the manager to take action in relation to these incidents. The use of bedrails was not safe for some people and the provider had not identified alternative methods of support to manage people at risk of falls.

There was a safeguarding log in place but no internal investigations, root cause analysis or thematic analysis of safeguarding incidents were carried out. Themes, trends and learning that could be used to improve the quality of care and support had not been identified.

We received mixed feedback from people who lived in St Mary’s Nursing Home. People told is they felt safe in St Mary’s Nursing Home. One person told us, “I feel very safe because I am well looked after and the staff are very nice but [the staff] don’t sit a lot and talk to you.” We spoke to family members and one person told us, “They do discuss [person’s] plan of care with me. I can call into the office at any time. [The staff] discuss [person’s] medication with me.” Our inspection found elements of care did not meet the expected standards of safety and person-centred care. Care records did not accurately reflect people’s care and support needs and there was a lack of person-centred care which meant people were not always treated as individuals.

The manager demonstrated a commitment to person centred care. Staff were aware of the need for person-centred care but overall care and support was not personalised to each individual.

Care was not always delivered safely and in line with care plans. One person was hoisted with the incorrect sling loop configurations and this was not in line with the loop configurations in their care plan.

Records of people’s care and support were not accurately recorded and maintained. The lack of accurate and up to date daily notes had an impact on the care and support provided for people and some of their needs were not met.

People told Us they felt safe in St Mary’s Nursing Home. One person told us, “I feel safe and well cared for. [The staff] are nice with me and my room is nice and mostly cleaned each day.” Another person told us, “You can sit out in the garden or in the shade.” Our inspection found elements of care did not meet the expected standards of safety and person-centred care. Care records did not accurately reflect people’s care and support needs and there was a lack of person-centred care which meant people were not always treated as individuals.

The manager understood the need for a safe environment and improvements were being put in place to ensure compliance with a recent enforcement notice issued by the Fire Service.

The care environment was not always safe. Radiators did not all have covers to minimise the risk of harm. Improvements to the care environment were in the process of being made to ensure compliance with the enforcement notice issued by the Fire Service. People wanted to sit outside and experience a different environment but they were not always supported to do so. The manager recognised this and took action following feedback as part of this assessment.

Aspects of the care environment were not safe and these had not been identified in the provider’s audits. Processes were in place to ensure any required repairs to the premises were escalated to the appropriate people, either maintenance staff on site or external contractors, to help ensure people’s health and safety was maintained.

We received mixed feedback from people who lived in St Mary’s Nursing Home. One person told us, “I feel safe because I can press my yellow button for somebody. Sometimes when I press I have to wait [for staff to come.]” Another person told us, “Sometimes they are short of staff. It is mostly short on a night or on a weekend. When I call for [the staff] it is usually half an hour before they come.” We spoke to family members and one person told us, “The staff are approachable and they care and understand [relative] and are good with [relative]. Often there are no staff upstairs and [people] are shouting. Often [people] ask me for things if there is nobody around.”

The manager identified the need for more effective communication and engagement with the staff team and had started making improvements but recognised this was the start of the journey.

Staff were available throughout the building but not always present on every floor. Staff were not responsive the needs of people who were cared for in bed or who chose to spend time in their rooms.

Staff practice was not always safe and staff were not always deployed effectively. An inspector had to alert a member of staff about the needs of a person but the member of staff did not go straight to the individual and had to be directed to the person's room to ensure they were safe. Daily notes did not record this issue and it was not mentioned to visiting professionals. Staff had been recruited appropriately and pre-employment checks were carried out.

We received mixed feedback from people who lived in St Mary’s Nursing Home. One person told us, “I feel safe and well cared for. [The staff] are nice with me and my room is nice and mostly cleaned each day.” We spoke to family members and one person told us, “[Relative] is always clean and their clothes are clean.”

No concerns around infection prevention and control (IPC) or supplies of personal protective equipment (PPE) were identified by staff. The manager took proactive action to ensure that all items in fridges were maintained safely.

There were no significant concerns identified in relation to IPC within the care environment. People's rooms and lounges appeared to be clean and well-maintained. We observed staff accessing, using, and disposing of personal protective equipment appropriately.

Policies, systems and processes were in place to monitor how the service managed infection prevention and control but they could be improved to promote good infection control. Staff received training in infection prevention and control.

We received mixed feedback from people who lived in St Mary’s Nursing Home. People told is they felt safe in St Mary’s Nursing Home. One person told us, “They deal with all my medication. I know what my medication is and what it is for.” Another person told us, “I am on a list to see the doctor every week. I get my medicine morning and night.” We spoke to family members and one person told us, “They do discuss [person’s] plan of care with me. I can call into the office at any time. [The staff] discuss [person’s] medication with me.” Another relative told us, "I have a list of [relative's] medication but I have noticed different things are on it. [The staff] will always give me an update." Our inspection found elements of care did not meet the expected standards of safety and person-centred care. Care records did not accurately reflect people’s care and support needs and there was a lack of person-centred care which meant people were not always treated as individuals.

There were no concerns about medicines identified by staff. Staff were trained to administer medications safely.

There were policies and procedures for administration of medications. The quality of PRN (as and when) protocols was inconsistent and this had not been identified on the provider’s audits. They did not make it clear how people indicate when there are in pain and unable to communicate verbally that they need pain relief. We observed that some medications were not stored appropriately. The manager took action when this was highlighted.