St Mary's Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The issues identified by CQC in relation to safe and well-led had not been identified by the provider. There was not an effective systematic approach to quality monitoring and clinical leadership and oversight in place. There was limited management oversight of audits and there was no evidence of verification that information in the audits was accurate and appropriate. People’s wishes and preferences for care had not been taken into account and alternative less restrictive solutions for managing risk had not been explored and implemented. There was a standardised approach to care and support and care was not personalised to the needs of the individual. The issues raised around good governance had been raised by CQC at the previous inspection and there had not been evidence of improvement in this inspection.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a culturally diverse workforce in place and policies and procedures helped to support an culture of inclusivity. There was limited knowledge and understanding of the local community and culture so that people who lived in the nursing home could access local activities and events.

There was limited understanding of a shared direction and vision for the service. People's care was not personalised and tailored to their individual needs.

The manager was capable and recognised the need to make improvements to the service. They were keen to hear feedback and used it constructively to identify actions for improvement.

The provider had limited clinical oversight, quality assurance and leadership and guidance for nursing and care staff. Policies and processes were in place but lack of oversight resulted in poor outcomes for some people.

The manager and the directors were positive about supporting people to speak up and have their voice heard. Staff recognised this.

The appropriate policies and procedures were in place that gave support to people to ensure their voice was heard.

The new manager had invested time in having staff meetings and discussions; staff felt more included and informed. The manager had organised additional training and support for staff.

We learnt as part of our assessment that many of the care staff are part of sponsorship schemes and had come to work in the UK from overseas. There was an equality and diversity policy in place and the provider aimed to create a working environment in which all individuals were able to make best use of their skills, free from discrimination or harassment, and in which all decisions were based on merit.

There was limited knowledge and understanding from the staff about the governance processes in place within the care home.

There was limited oversight, monitoring and review of service by the provider. They were on-site during the inspection but did not spend time looking at quality systems and clinical and care practice. There was limited management oversight of audits and no evidence of verification that information in the audits was accurate and appropriate or that people’s wishes and preferences for care had been taken into account or that alternative less restriction solutions for managing risk had been explored and implemented. There was a standardised approach to care and support. Care was not personalised to the needs of the individual, for example, many people had bed rail assessments in place with the only reason given as 'Safety'. There had not been a clinical or management review of the these assessments and alternative solutions to manage people's needs had not been explored. The issues identified by CQC in relation to safe and well-led had not been identified by the Provider. There was not an effective systematic approach to quality monitoring and clinical oversight in place. The issues raised around good governance had been raised by CQC at the previous inspection and there has not been evidence of improvement in this inspection.

People told us they wanted to go out more often. One person told us, " I would love to go to the seaside but there are no trips." The service had made some efforts to support people to sit outside whilst the weather was pleasant but overall there were limited opportunities for people to access their local community and for members of the local community to engage with people who lived in the nursing home.

The manager of the care home recognise the value of working closely with partners and the local community. They welcomed all partners into the care environment and valued their constructive feedback and support. A member of staff told us, "We take people in to town and sometimes we go to the shops and a cafe. We would like to organise trips if we could."

Partners recognised the efforts of the manager to engage with them and embrace feedback when improvements where identified. There was limited assurance about how clinical staff understood the local NHS pathways, systems and processes which impacted on the quality of clinical care and support for people who lived in St Mary's Nursing Home.

The home was under scrutiny from local multi-agency teams in relation to concerns about the quality of care. The manager demonstrated their willingness to work with partners effectively to meet people’s needs. The manager was starting to build relationships with the local community and local partners. The manager welcomed feedback on the care people received as this helped drive improvement.

There was limited support and clinical leadership and oversight for clinical staff. This had an impact of the quality of care and support provided. The manager of the service recognised the value of a culture of continuous learning and improvement.

There was limited quality assurance, service management and oversight by the Provider. Clinical leadership systems and processes were not effective and impacted on the quality of clinical care delivered by staff. We were not assured that previous concerns identified and raised led to continuous improvement and learning shared across the home. This placed people at the risk of harm and we were not assured people were always safe and receiving good quality and effective care that met their needs.