Updated 8 February 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 Care Act 2014.
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
One inspector and a specialist advisor carried out this inspection, and an Expert by Experience made telephone calls to people’s relatives. 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 or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
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 not a registered manager in post. A new manager had been in post for three months and had applied to register. We are currently assessing this application.
Notice of inspection
This inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We spoke with the manager, deputy manager, a senior care worker, nurse, laundry assistant, head chef, 3 care assistants and an activities coordinator. We received email feedback from another care assistant. We spoke with 2 people who used the service about their experience of the care provided. We spoke with 10 relatives via telephone. We reviewed a range of records. This included 4 people’s care records and multiple medication records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service were reviewed. 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.