St Marys

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment due to concerns we found relating to the environment.
 

This service scored 59 (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 did not always have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice, and the provider did not have a consistent approach to learning from incidents or feedback. Learning tended to occur reactively rather than as part of a proactive, open learning culture.

The culture within the home did not consistently support open reflection or recognise that mistakes and areas for improvement could occur in everyday practice. The registered manager told us they did not feel there were lessons to learn because the service “does not make mistakes.” However, several concerns had been identified during our assessment and had subsequently been actioned following our feedback. As a result, opportunities for proactive learning were reduced and reflective discussions did not routinely occur.

The home had not recorded any complaints when relatives had previously discussed problems with them. This approach meant improvements were not always embedded into routine work and there was not continual improvement through reflection and learning from complaints.

However, people and their relatives knew who the registered manager was and felt able to raise concerns or concerns if they had any. There was a caring ethos within the home, and long-standing staff showed strong commitment to the people living there. Concerns we raised during our assessment were listened to, and actions were taken by the management team to make improvements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Pre-admission assessments coordinated handovers and clear discharge information supported safe care. For people living with dementia, staff planned moves in advance, used plain-language and familiar objects to reduce disorientation, and ensured signage and orientation cues were in place on arrival. The registered manager said, “The family will come and sit with us, and I get a lot of information from the family before they come. Sometimes the resident will come and have a look around themselves.”
Information followed the person, so they did not need to repeat their history, and responsibilities for follow-up appointments, equipment and reviews were agreed and recorded, which reduced avoidable delays and duplication.

The provider worked with health care partners to safeguard people. However, improvement was needed to ensure training relating to safeguarding was reviewed and updated to ensure incidents were promptly identified and reported.

Whilst most staff had been trained to recognise and report all forms of abuse and knew how to escalate concerns to the local authority and the Care Quality Commission, some staff had not had their training renewed, including the safeguarding lead for the service. The safeguarding policy had been reviewed but the incorrect name had been entered for the safeguarding lead, which was for someone who did not work at the service. This was an administration error which was quickly rectified but had not been noticed prior to our assessment.

However, safeguarding processes ensured people were protected from abuse and improper treatment. Staff understood their responsibilities, recognised signs of concern and acted promptly. People expressed confidence that staff would listen. Staff were skilled and proactive when people showed distress, communicated a need, or expressed feelings. Care plans were clear and detailed.
The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

Risks were identified and recorded with guidance for staff on how to manage risks. Support plans and risk assessments identified potential risks to people’s safety and provided staff with enough guidance on how to support service users safely. The registered manager had a good understanding of implementing the least restrictive options for people. The provider was aware of how to involve people to manage risks including working with family or advocates where needed. The provider ensured if someone did not have capacity, they went through a Mental Capacity Act (MCA) assessment. This helped to ensure people received fair treatment and advocacy support when needed.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We found some environmental risks had not been identified prior to our visit and action taken to mitigate those risks. Some tall furniture was not secured to the wall, creating a risk of tipping, and windows throughout the building had no restrictors, meaning they could be opened wide and posed a potential safety hazard. In many bedrooms, there were limited electrical sockets, which meant staff and people living in the home relied on extension leads. Some of these were overloaded or positioned in ways that created trip hazards or risks of items falling. For example, in the lounge we found an extension lead supplying multiple devices, including the television which was hanging by the attached cables and if they were pulled or caught, the television or another device could potentially fall and cause injury. There was also a bed which had been placed on the landing without first risk assessing this, which posed a risk of harm from trips and falls.

We reviewed the home’s current legionella risk assessment from 2023 which had highlighted that the hot water temperature in one bedroom was too high. When we tested this during our assessment, the water temperature remained above safe levels, posing a scald risk. This was despite maintenance records indicating the temperatures had been checked and were within a safe range.
The red fire bag was stored on top of a unit in the manager’s office which was kept locked. If there was an emergency at night this was not readily available which could delay evacuation. The registered manager rectified this following our assessment.

This meant people were at risk of avoidable harm because the environment was not being consistently monitored or maintained safely. The provider acted promptly and addressed the identified hazards following our feedback.

The provider did not always make sure there were enough qualified, skilled, and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. Recruitment practices were not always safe or compliant with legal requirements. Several staff files were incomplete and had essential pre-employment checks missing. This included new staff and those who had moved into more senior roles.

There was a Disclosure and Barring Service (DBS) identification requirements sheet which recorded the DBS reference number and what identification had been checked but did not record which type of check the person had, when the certificate was obtained and when a recheck was needed. These files also did not evidence if the DBS checks were clear or if there were disclosures which would need to be risk assessed prior to the staff members commencement of employment.

There were also gaps in employment histories, with no evidence that these had been explored or verified. References were mainly character references and were often not from the most recent employer or contained insufficient detail to confirm a person’s suitability for the role. Where people had changed roles, it was not clear how, when, or why the change had occurred.

These shortfalls meant leaders could not be assured staff had the right character, background, or experience to work safely. The failure to follow safe recruitment procedures left people at risk because unsuitable individuals may have been employed without appropriate checks. Records also indicated staff had not all received training in all areas or had certain training updated when it had needed to be renewed.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed a dedicated team who ensured the environment was hygienic and free from odour. Staff followed the cleaning schedule and used appropriate personal protective equipment to help protect people from risks related to cross infection. People told us staff wore gloves and aprons during personal care. People were supported to maintain cleanliness in their own bedrooms, and these spaces were personalised and comfortable. Relatives told us the home felt welcoming and well cared for. One relative said, “It’s clean and it’s friendly and comfortable. The staff are lovely, every single one of them. They’re professional, kind, and pleasant.” Another said, “It’s not the poshest home, but it’s clean and their care is very good.”

However, the provider could not demonstrate that Infection Prevention and Control (IPC), training had been maintained for all staff. This reduced assurance that all staff were confident and up to date in IPC practice. We also found there were some windows and windowsills with peeling paint. Peeling or damaged surfaces cannot be effectively cleaned, which increases the risk of bacteria harbouring and reduces infection control reliability. This issue had been present long enough that it should have been identified through routine IPC checks. Following our assessment the management team told us the windows would be replaced during drier weather in 2026.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happened.
People’s medicines were managed safely; staff followed procedures for administering, storing, and recording medicines. Reviews were carried out to ensure people continued to receive the right treatment. Staff understood how people communicated discomfort and needs, and medicines support aligned with these individual communication approaches.
Medicines were collected, reviewed and records updated to ensure accuracy across transitions of care, such as on admission and after hospital visits. Staff administered medicines in line with the provider’s policy and recorded them accurately on Medication Administration Record (MAR) charts; records showed clear signatures, reasons for any omissions and appropriate codes.
‘As required’ medicines had person‑specific directions, stock balances matched usage, and temperatures for rooms and fridges were monitored. Reviews with the GP and pharmacist reduced unnecessary medicine storage and supported safe disposal of returns.