We carried out a review of the data available to us about St Mary's Convent on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Mary's Convent, you can give feedback on this service.
St Mary's Convent is a residential care home which provides older people with personal care. The home can accommodate up to 18 people. On the day of our inspection visit, 18 people were using the service.
People’s experience of using this service and what we found
People and their relatives told us the care was safe and they were happy at St Mary's Convent. Medicines were managed safely, there were enough staff on duty and staff were recruited safely. Many staff had worked at the service for several years. People were protected from abuse by staff who understood how to identify and report any concerns. People were protected from harm as risks had been assessed and plans put in place to mitigate these.
Senior staff carried out detailed assessments of need to ensure the home could effectively support any new admissions. People were supported to have enough to eat and drink and staff were trained to support people who had different dietary needs. Staff told us they were well trained and they were well supported and supervised by the management team. The service worked well with community healthcare partners to ensure people received healthcare support where needed.
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.
Interactions between people and the staff team were very positive and relatives also said they were made very welcome at the home. We spoke with relatives visiting their loved one close to the end of their life, they told us they were very supported and thankful to the staff team. People were treated with kindness, dignity and respect.
People received personalised care that was responsive to their needs and preferences. People were supported to engage in activities to reduce their risk of social isolation. People were supported to express their spirituality, with whatever religion they chose to follow. The home held regular Catholic mass and services in their peaceful chapel which was open to the community. People and their relatives knew how to make a complaint, although nobody we spoke with had any.
There was a clear management structure and staff were supported by the registered manager. People's feedback was sought regularly and acted upon. We received positive feedback about how the service was managed. Quality assurance systems were completed.
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 rating for this service was good (published 05 July 2017).
Why we inspected
This was a planned inspection based on the previous rating.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Mary's Convent on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
The service provides accommodation and personal care for up to 18 older people. Nursing care is not provided. St Mary's Convent is located in the village of Ebchester in County Durham. At the time of our inspection there were 15 people using the service.
There was a registered manager in post. A registered manager is a person who has registered with the CQC to manage the service. Like providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
There were safeguarding procedures in place. Staff were knowledgeable about what action they should take if abuse was suspected and people told us they felt very safe living at St Mary’s Convent.
The premises were clean. Checks and tests had been carried out to ensure that the premises were safe.
We found that recruitment checks were carried out to ensure that staff were suitable to work with vulnerable people.
Sufficient staffing levels were provided to meet the needs of people using the service. We observed staff carry out their duties in a calm, unhurried manner and people were supported to access the local community. Records confirmed that training was available to ensure staff were suitably skilled. Staff were supported though an appraisal and supervision system.
Risk assessments were in place when required and accidents and incidents were appropriately recorded and analysed.
Appropriate arrangements were in place for the administration and storage of medicines.
The provider was working within the principles of the Mental Capacity Act 2005 (MCA) and was following the requirements in the Deprivation of Liberty Safeguards (DoLS).
People's nutritional needs were met and they were supported to access healthcare services when required.
We observed positive interactions between staff and people who lived at the service. People and visitors we spoke with told us the staff team were very caring. Staff promoted people's privacy and dignity.
Care plans were in place which detailed the care and support to be provided for people. These were regularly reviewed and updated where necessary.
People were supported to maintain their links with families and local community. There were a range of activities which people enjoyed and activity staff supported people to access the local community on a regular basis. There was a complaints procedure in place. Feedback systems were in place to obtain people’s views.
The provider was meeting the conditions of their registration. They were submitting notifications in line with legal requirements. They were displaying their previous CQC performance ratings at the service.
The inspection was unannounced. This meant the provider or staff did not know about our inspection visit.
St Mary’s Convent provide care for up to 18 older people. Nursing care is not provided. The home was established as a care home in 1934.
The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.’
The service was last inspected by CQC on 27 May 2014 and was compliant.
There were sufficient numbers of staff on duty in order to meet the needs of people using the service. The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.
We saw evidence that thorough investigations had been carried out in response to safeguarding incidents or allegations.
We saw a copy of the provider’s complaints policy and procedure and saw that complaints had been fully investigated. During the last 12 months, we found no complaints had been received.
We saw comprehensive medication audits were carried out regularly by the management team.
Training records were up to date and staff received regular supervisions and appraisals, which meant that staff were properly supported to provide care to people who used the service.
We saw staff supporting people in the dining rooms at lunch and choices of food and drinks were being offered.
All of the care records we looked at contained care plan agreement forms, which had been signed by the person who used the service or a family member.
The home was exceptionally clean, spacious and suitable for the people who used the service.
CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. They aim to make sure that people in care homes, hospitals and supported living are looked after in a way that does not inappropriately restrict their freedom. We discussed DoLS with the registered manager and looked at records. We found the provider was following legal requirements in the DoLS.
People who used the service, and family members, were extremely complimentary about the standard of care.
We saw staff supporting and helping to maintain people’s independence. We saw staff treated people with dignity, compassion and respect and people were encouraged to remain as independent as possible.
We saw that the home had a full programme of activities in place for people who used the service.
On the day of our inspection most people attended mass in the convents chapel. In the afternoon people were actively involved in a music quiz. Several others were out with family and friends.
All the care records we looked at showed people’s needs were assessed before they moved into the home and we saw care plans were written in a person centred way.
The provider had a robust quality assurance system in place and gathered information about the quality of their service from a variety of sources including people who used the service and their family and friends.
Below is a summary of what we found. The summary is based on our observations during the inspection and speaking with people using the service, and the staff supporting them and from looking at records.
If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
People told us they were treated with respect and dignity by the staff. They said they felt safe. We found safeguarding procedures to be robust and staff understood how to safeguard the people they supported.
Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.
The home had proper policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We also found relevant staff had been trained to understand when an application should be made, and how to submit one. This meant people were safeguarded as required.
The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk.
The registered manager set the staff rotas, they told us they took people's care needs into account when making decisions about the staffing numbers, qualifications, skills and experience required. This helped to ensure that people's needs were met.
Is the service effective?
There was an advocacy service available if people needed it, this meant people could access additional support when required.
People's health and care needs were fully assessed with them, and they or their representatives were fully involved in writing their plans of care.
Specialist dietary, social, mobility, equipment and dementia care needs had been identified in care plans where required.
People's needs were taken into account with signage and the layout of the service enabling people to move around freely and safely. The premises had been sensitively adapted to meet the needs of people with physical, memory and mental health impairments.
People who used the service confirmed they were able to see people in private and that visiting times were flexible.
Is the service caring?
People told us they were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people. People commented, 'The staff are very good. They put me at my ease,' 'This is a wonderful place to live. They look after me very well, there is a good choice of home cooked food. It's really nice here. 'I have a bell in my room. When I pull it the staff come quickly' and 'They the staff are very good. They would get the doctor quickly if I was unwell.' A relative told us that the care at St Marys Convent was excellent. Another told us, 'I couldn't fault the care my relative receives.'
People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised, we saw these had been addressed by the provider.
People's preferences, interests, aspirations and diverse needs were recorded and care and support was provided in accordance with people's wishes.
Is the service responsive?
People completed a range of activities in and outside the service regularly.
People we spoke with knew how to make a complaint if they were unhappy.
Is the service well-led?
Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and the quality assurance systems in place. The records we looked at showed any shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. This helped to ensure that people received a good quality service.
The service worked well with other agencies and services to make sure people received their care in a joined up way.
Suitable arrangements were in place for people to take part in activities in line with their needs and preferences. The relationships between staff and the people who lived there were good and personal support was provided in a way that promoted and protected their privacy and dignity.
Suitable arrangements were in place for handling complaints and for protecting people from abuse. Three people told us they could share any concerns with the staff and felt their views were listened to. Another person said 'This place is just wonderful it is my home now. I have lived here for 2 years. I like living here because all my needs are taken care of and I feel safe.' A friend of a resident said "I have no concerns everything here is great."
There was a stable and competent staff team who had the training, skills and experience to meet the specific conditions of the people who lived there.
Three service users spoken with confirmed they were able to visit the home prior to admission for meals, overnight stays and trial visits. They also confirmed staff visited them in their own homes prior to their admission and provided them with information about the home.
Three service users and one relative spoken with said visiting times were flexible and they could see their visitors in private at anytime. Service users confirmed staff helped them to maintain contact with their family and friends and they could choose who to see and who not to see.
One person said, 'I came for a period of respite care and this helped me to decide that I wanted to live here. All my needs are fully met, and the care I receive is wonderful.'
A relative told us, 'My mother made the decision herself to come and live here, that was four years ago. The care here has been first class, and we have no complaints at all.' Another person told us, 'I am treated with respect at all times and they listen to what I have to say.'
All service users spoken with said daily routines were flexible and varied. They confirmed they were able to choose how they spent their day and what leisure activities to join in with. They said they were able to pursue their own interests and could choose what social/cultural activities to participate in. They said they were very satisfied with the care and support they received. One person told us, 'I have more opportunities now to socialise with friends in the community than I had before coming to live here.'
Service users told us the food was very good and a choice was always available.
They said meal times were flexible and they could have a meal in their room if they wished. One person told us, the food was always fresh and home cooked from scratch, she said, 'we don't have any processed food here, and I know because I used to be a cook myself.'
One relative confirmed they had been given copies of the complaints procedure and they were confident any concerns they might have would be dealt with fairly. They told us during the last four years there had never been a need to make a compliant or raise a concern.
One service user told us, 'I have no concerns at all, I feel safe and cared for here.'
People told us they always got their medicines at the right times.
Staff told us they had lots of opportunities for their personal development.
One member of staff told us, 'I have completed my NVQ (National Vocational Standards) level 5 in care and management. I gained a great deal of satisfaction from doing so.'