St Marys Care Centre

Updated 24 June 2022

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 Health and Social Care Act 2008.

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

The inspection was completed by two inspectors and an Expert by Experience. 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 Care Centre is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Mary’s Care Centre is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. A manager was in post and had started the process to be registered with the CQC.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority safeguarding team and quality assurance team.

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 nine people who use the service, and 12 relatives about the experience of care provided. We spoke to 11 staff including kitchen staff, domestic staff, care assistants and the management team.

We reviewed six care plans and various records relating to the health and safety of the building. We reviewed four staff files looking at their recruitment, supervision and training. We reviewed the provider’s policies and procedures.

We sought advice and shared our findings from the inspection with the local Infection Control Team.

Updated 24 June 2022

About the service

St Marys Care Centre is a residential care home providing personal and nursing care up to 60 people. The service providers support to older people, some of whom may be living with dementia or a physical disability. The premises are on one ground floor level split into two areas; residential and nursing. At the time of the inspection, there were 47 people using the service.

People’s experience of using this service and what we found

The service had recently had a change in management, including a new manager and clinical lead. The manager had started to make changes to the service, but these were not yet embedded.

There was a lack of consistency in how well the service was managed and led. Systems in place were ineffective at identifying risk. The provider had failed to ensure effective infection and prevention control measures were in place.

We received mixed feedback about the quality and quantity of food provided. We fed back people’s experiences regarding the quality and quantity of food to the provider. They told us they were confident people’s dietary needs were being met. We have made a recommendation about this.

People were not always supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. We have made a recommendation about this.

Staff training, appraisals and supervision had not been kept updated. The service continually reviewed their staffing levels and had recently increased these. However, people told us that they felt the service was short staffed. People felt rushed and did not feel their care was person centred.

Complaints had not always been dealt with in line with the provider’s policy. Relatives found raising concerns difficult. We made a recommendation for the provider in relation to complaints.

Medicines were managed safely.

Staff were kind and caring but did not always promote people's dignity and privacy.

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 13 February 2021).

At our last inspection we recommended that the provider sought advice and reviewed their practice in relation to IPC practice. We made a second recommendation in relation to governance and oversight of the service.

At this inspection we found that these recommendations had not been actioned sufficiently.

Why we inspected

The inspection was prompted in part due to concerns received about medicines management. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the management of risk, person centred care, governance and oversight at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.