St Marys

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.At our last assessment we rated this key question good. At this assessment, the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.
 

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them. People's needs were assessed before they moved into the service. The information was used to create their care plans. Care plans contained detailed information on how best to support people to ensure what was important and what mattered to people was included in their day-to-day support. Care plans were paper based, but staff knew how to access this information about people including where it was stored.
We found that documents did not always reflect that family members or the individual had been included in the care plan review. However, people and their relatives told us they were kept informed and involved in their care plans and risk assessments and said they could ask to change their care plan when they needed to.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

People were engaged throughout the day, and staff demonstrated a clear understanding of how to tailor support to individual needs. Where clinically indicated, staff completed Waterlow assessments to identify pressure‑ulcer risk and used the outcomes to plan repositioning, skin checks and equipment needs. The Waterlow score is a tool that helps staff assess a person’s risk of developing pressure ulcers so appropriate prevention measures can be put in place. Where assessments identified risk, staff implemented preventative actions, monitored outcomes, and records showed this had reduced avoidable skin damage.
Records showed nationally recognised assessment tools were used to assess people’s risks. For example, staff used the Malnutrition Universal Screening Tool (MUST), a simple assessment that helps identify people who may be at risk of malnutrition so they can receive the right support. The records we reviewed showed people had maintained stable weights or experienced modest gains within healthy ranges.
Relatives told us people enjoyed the food, including the traditional menu and home‑style cooking. One relative said, “Their appetite has gone through the roof since they’ve been there. They love their dinner and they get a choice.”

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.
Staff knew people and worked effectively together as a team to ensure their needs were met. Staff worked effectively with other professionals to ensure people received timely and coordinated care. Staff worked well with external professionals to ensure transitions were well coordinated and planned in line with people’s preferences. The management team worked with health and social care professionals to ensure people’s needs were met. This meant people received coordinated care from teams who communicated well and worked together effectively.

The provider supported people to manage their health and wellbeing to maximise their independence, choice, and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

When people needed medical support, this was sought to prevent any deterioration of health and wellbeing. Families were kept informed of any changes and actions taken. People were supported to access health care professionals when needed. For example, the GP and district nurses. One relative told us, “If it wasn't a massive emergency they would crack on and call the GP, but they would still keep you informed.”People were also supported to attend external appointments, such as hospital appointments. Where health professionals were involved in people’s care this was appropriately documented in records to support care delivery.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

We found daily notes documentation not being completed timely and needed to be reviewed and improved, particularly to prevent risks associated with hydration. For example, we saw one person’s daily record and fluid chart showed entries that did not reflect the morning’s events. More widely, staff indicated that morning and lunchtime intakes were often recorded retrospectively around 1pm, with staff writing up from memory rather than at the point of care.

However, earlier in the day, staff were heard prompting one another saying ‘Has anyone been up to [name] and given them more fluids? Have you documented it? Make sure someone keeps going up.’ This showed staff were attentive to people’s needs, but documentation did not always evidence this, highlighting the absence of a robust, real time recording process. This reduced the reliability of hydration data and could obscure early signs of dehydration risk.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment. People and their relatives told us they were treated with respect, dignity, and kindness. Consent was sought from people and where necessary relatives had been involved in decisions made on the persons behalf, in accordance with the Mental Capacity Act 2005 (MCA). The registered manager said, “We talk all the time to families, and we make joint decisions with the families.”A clear process was in place to carry out mental capacity assessments where required. Mental capacity assessments were thorough and specific to the person and the decision being made. Care was planned in the person’s best interest, in the least restrictive way and in consultation with others.