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Inspection Summary


Overall summary & rating

Good

Updated 15 September 2017

Saint Mary’s Nursing Home provides accommodation, nursing and personal care for up to 40 older people, some people are living with dementia.

There were 28 people living in the service when we inspected on 14 August 2017. This was an unannounced inspection.

We carried out an unannounced comprehensive inspection of this service on 28 September 2015, we found breaches of regulation that affected the well-being of people using the service, this included safety, staffing and how the provider monitored the service that people received. The overall rating for the service was ‘Inadequate’. At a further comprehensive inspection of 27 June 2016 we found that there had been improvements made and the service was rated ‘Requires improvement’ overall. These improvements needed to be embedded in practice and sustained. The registered manager sent us reports on a monthly basis which kept us informed of the improvements they were making.

You can read the report from our last inspection, by selecting the 'all reports' link for Saint Mary’s Nursing Home on our website at www.cqc.org.uk.

At this comprehensive inspection of 14 August 2017 we found that the improvements previously made had been sustained and further improvements had been implemented.

There was a registered manager in post. 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.

There were robust systems in place which supported the registered manager to monitor and assess the service provided to people. These systems allowed the provider and registered manager to effectively address shortfalls, take action to address them and put measures in place to minimise the risks of similar issues arising in the future.

Staff were provided with the training and support that they needed to meet people’s needs. There was a training plan in place to ensure that the staff’s knowledge was kept up to date. People had good relationships with the people using the service. People were treated with care and their independence, privacy and dignity was promoted and respected.

Systems were in place to minimise the risks to people and to keep them safe. This included risk assessments to identify how assessed risks were minimised and processes designed to keep people safe from abuse.

There was a system in place to assess how many staff were needed to meet people’s assessed and changing needs. This was kept under review to ensure that staffing numbers were increased if people required more care and support or if more people used the service. There were safe staff recruitment processes in place.

People’s care records had been reviewed and updated, they were more person centred and included the input from people and their representatives. Improvements had been made in the social activities provided for people to participate in to reduce the risks of isolation. There were plans in place to develop these further.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Improvements had been made in the infection control and environment. Systems were in place to monitor the cleanliness of the service. There was an ongoing refurbishment plan in place.

People were provided with their prescribed medicines safely and when they needed them.

People’s dietary needs were assessed and actions were taken when there were concerns about people’s wellbeing relating to their nutrition and hydration. People were supported to see, when needed, health and social care professionals.

There was a complaints procedure in place and systems to respond and address to people’s comments, concerns and complaints.

Inspection areas

Safe

Good

Updated 15 September 2017

The service was safe.

Staff knew how to keep people safe from abuse. There were systems in place designed to keep people safe from harm.

There were systems in place to assess the numbers of staff required to meet people’s needs. The recruitment of staff was undertaken safely.

People were provided with their medicines when they needed them and safely.

Effective

Good

Updated 15 September 2017

The service was effective.

Staff were trained and supported to meet the needs of people who used the service.

The service worked in line with the requirements of the Mental Capacity Act 2015.

People’s nutritional needs were assessed and met. People were supported to maintain good health.

Caring

Good

Updated 15 September 2017

The service was caring.

Staff interacted with people in a caring manner. People’s independence, privacy and dignity was promoted and respected.

People and their relatives were involved in making decisions about their care.

Responsive

Good

Updated 15 September 2017

The service was responsive.

People’s wellbeing was assessed, planned and delivered to meet people’s needs.

People were provided with the opportunity to participate in activities that interested them.

Complaints were addressed and acted on.

Well-led

Good

Updated 15 September 2017

The service was well-led.

There were quality assurance systems in place. These helped the provider and registered manager to identify shortfalls and address them. As a result the service continued to improve.