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Inspection Summary


Overall summary & rating

Good

Updated 22 February 2018

We inspected this service on 15 January 2018. The inspection was unannounced.

St Marys is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single packages under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Marys accommodates up to 23 older people including people living with dementia. On the day of our inspection 14 people were living permanently at the service and three people were receiving respite care.

The service had a registered manager at the time of our inspection. 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the home’s previous inspection in January 2017 we identified one breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was in relation to Regulation 17 Good Governance. Systems in place to check on quality and safety were not as effective as they should have been. Following this inspection the registered provider was required to send us an action plan to inform us of the action they would take to make the required improvements.

During this inspection we checked to see whether improvements had been made, we found the breach in regulation had been met and all areas of the service had improved resulting in positive outcomes for people.

People were protected from potential abuse and avoidable harm because staff were aware of their role and responsibilities and had received safeguarding training that informed their practice. Risks in relation to people's needs including the environment were assessed, planned for and monitored.

Action had been taken to improve the internal environment, this included some refurbishment work, repairs and replacement of furnishings.

There were sufficient staff employed and deployed to support people. Safe staff recruitment practice was in place and followed. People received their prescribed medicines safely and these were managed appropriately. Protocols in place to advise staff of medicines prescribed to be taken as and when required were not consistently detailed.

People lived in a clean, hygienic service and there was a prevention and control of infections policy and procedure guidance to support staff. Staff supported people effectively during periods of anxiety that affected their mood and behaviour. Accidents and incidents were reported, monitored and reviewed to consider the action required to reduce further reoccurrence.

People were supported effectively by staff that knew and understood their individual needs. Staff received an appropriate induction, ongoing training and opportunities to discuss their work, training and development needs. New staff had not always received training in a timely manner but action was taken to immediately address this.

People's dietary needs had been assessed and planned for and they received a choice of meals and drinks. Systems were in place to share relevant information with other organisations to ensure people's needs were known and understood. People were supported to access healthcare services and their health needs had been assessed and were monitored. Staff worked well with external health care professionals in managing people’s health needs and outcomes.

People had 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. The principles of the Mental Capacity Act (2005) were followed when decisions were made about people's care. Deprivation of Liberty Safeguards were in place for some people where required.

People were supported by staff who demonstrated a good understan

Inspection areas

Safe

Good

Updated 22 February 2018

The service was safe.

People were protected from abuse and avoidable harm and improvements had been made to the environment resulting in risks being reduced.

Staff were informed about how to provide safe care and support.

People were supported by a sufficient number of staff who had been recruited safely.

People received their prescribed medicines safely and these were managed appropriately. Documentation for medicines prescribed as and when required were not all consistently completed.

The service was clean and hygienic and staff were aware of infection control measures.

Effective

Good

Updated 22 February 2018

The service was effective.

People were supported by staff who received appropriate training and supervision and had an understanding of people’s care needs. New staff had not always received training in a timely manner but this was immediately addressed.

People’s mental capacity to make decisions was assessed. DoLS had been applied for when required.

People’s nutritional needs had been assessed and planned for. People received a choice of meals and were supported to eat and drink sufficiently.

Staff understood people’s healthcare needs and their role in supporting them with these. Staff worked well with external healthcare professionals.

Caring

Good

Updated 22 February 2018

The service was caring.

People were cared for and supported by staff, who respected them as individuals who knew them well.

People and their relatives were involved as fully as possible in discussions and decisions about their care and support.

Staff had developed positive relationships with people and respected their privacy and dignity.

People had independent advocacy information made available to them.

Responsive

Good

Updated 22 February 2018

The service was responsive.

People’s needs were assessed before they started using the service. People’s communication and sensory needs had been assessed and planned for.

People were offered opportunities to take part in social activities.

People were given opportunities to make a complaint or raise concerns about the service they received.

Well-led

Good

Updated 22 February 2018

The service was well-led.

Improvements had been made to all areas of the service. The staff team were clear about their role and responsibilities and confirmed improvements had been made.

People and their relatives and others, received opportunities to share their views about the service.

Improvements in the systems in place to check on quality and safety were more effective and embedded.