We carried out a review of the data available to us about St Mary's Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Mary's Home, you can give feedback on this service.
About the service
St Mary’s Home is a residential care home consisting of seven living areas or flats, which can support up to 40 people. The service was providing personal care to 35 people at the time of the inspection.
People’s experience of using this service and what we found
Right Support – Effective risk management plans were now in place. Risk assessments were updated and clear guidelines in place to guide staff as to how to support people.
The numbers and skills of staff matched the needs of people using the service. Staff recruitment and induction training processes promoted safety, including those for agency staff. Staff knew how to take into account people’s individual needs, wishes and goals. People continued to be supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely.
Right Care - People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to. Staff knew people well and interacted positively with them.
Staff helped people to have freedom of choice and control over what they did. People were supported to participate in their chosen social and leisure interests on a regular basis.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right culture – Governance processes were effective in ensuring records management was consistent to keep people safe, protect people’s rights and provide good quality care and support. Important incidents were now being reported to the Care Quality Commission.
The provider sought feedback from people and those important to them and used the feedback to develop the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Requires Improvement (published 25 July 2022).
The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was carried out to follow up on action we told the provider to take at the last inspection.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.
About the service
St Mary’s Home is a residential care home consisting of seven living areas or flats, which can support up to 40 people. The service was providing personal care to 36 people at the time of the inspection.
People’s experience of using this service and what we found
Right Support – People's care records did not always reflect the support they needed, as effective risk management plans were not always in place. Risk assessments required some improvement to ensure that clear guidelines were always in place to guide staff as to how to support people. Staff received regular training, supervision and appraisal. People were supported with their dietary needs and to access healthcare professionals.
The numbers and skills of staff matched the needs of people using the service. Staff recruitment and induction training processes promoted safety, including those for agency staff. Staff knew how to take into account people’s individual needs, wishes and goals. People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely
Right Care - People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to. Staff were patient and used appropriate styles of interaction with people.
Staff supported people to express their views using their preferred method of communication. Staff took the time to understand people’s individual communication styles and develop a rapport with them.
Staff helped people to have freedom of choice and control over what they did. People were supported to participate in their chosen social and leisure interests on a regular basis.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Right culture – Governance processes were not always effective in ensuring records management was consistent to keep people safe, protect people’s rights and provide good quality care and support. Important incidents were not always reported to the Care Quality Commission.
The provider sought feedback from people and those important to them and used the feedback to develop the service.
Staff felt respected, supported and valued by senior staff which supported a positive and improvement-driven culture. Managers set a culture that valued reflection, learning and improvement and they were receptive to challenge and welcomed fresh perspectives.
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 22 February 2018).
Why we inspected
We undertook this inspection to assess that the service is applying the principles of Right support right care right culture.
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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
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 good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
St Mary’s Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
St Mary’s Home provides care and support for men and women with learning disabilities, some of whom have physical disabilities and dementia. The home can accommodate up to 40 people. On the day of our visit there were 33 people using the service. The home is situated over four floors. It is located on the High Street in Roehampton and is close to all amenities including shops, cafes and restaurants. The home is managed by The Frances Taylor Foundation which is part of the UK charity the Poor Servants of the Mother of God.
At the last inspection the service was rated Good, at this inspection we found the service remained Good.
The service had a registered manager in post. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We made a recommendation for the service to review their procedures in relation to how people’s emergency epilepsy medicines were managed and stored.
Risk management plans were in place and staff were aware of how to support people if they had an epileptic seizure. The service carried out investigations and took actions as a result of the safeguarding alerts raised. There were suitable recruitment procedures in place to ensure staff’s on going suitability for the role. Staff levels were monitored and increased where needed to provide the necessary support for people. Staff were aware of and used appropriate equipment to provide hygienic care for people. People received their medicines as prescribed and staff stored the medicines safely as required. The service took actions to mitigate the incidents and accidents occurring.
The service followed the Mental Capacity Act (2005) principles to support people to make decision where necessary. However, the records we looked at lacked details and information on how the decisions were made.
The manual handling equipment used was adapted to people’s individual needs. Staff were appropriately trained and the management team had encouraged them to gain a qualification in the care sector. People had their dietary needs met and told us about the choices they made around the meals they wanted to have. The service worked in partnership with healthcare professionals to ensure joined-up care for people. People told us that St. Mary’s Home was their home and felt comfortable living there.
Staff showed a caring attitude in helping people where they needed assistance. People had their dignity and privacy respected. The staff team understood people’s communication needs and helped them to express themselves if they needed support. People had assistance to build and maintain important relationships to them. People made suggestions around the choice of activities provided for them. Staff encouraged people to have control over their lives and access community independently where possible.
People’s care plans were personalised, detailed and reviewed regularly. People had support to write their own care plans. People’s complaints were investigated and responded to as necessary which gave people confidence to raise their concerns if they had any. Relatives were involved in people’s care planning and provided regular feedback for making improvements where necessary.
The management team were passionate in delivering care for people that made them feel dignified and valued. People and their relatives told us the management team was approachable then they needed to talk to them. The staff team had shared responsibilities to ensure smooth running of the service. Staff were encouraged to share their experiences and concerns if they had any. Quality assurance audits were carried out at all levels to review the quality of the services being delivered for people.
This inspection took place on 27 October and 5 November 2015 and was unannounced. The provider knew we would be returning for a second day. At our previous inspection on 23 January 2014 we found the provider was meeting the regulations we inspected.
St Mary's offers residential care for up to 42 men and women with learning disabilities. It is located on the High Street in Roehampton and is close to all amenities including shops, cafes and restaurants. It is managed by The Frances Taylor Foundation which is part of the UK charity the Poor Servants of the Mother of God.
There was a registered manager at the service. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People using the service told us that staff treated them well and that the service felt like home. They praised staff for their caring attitude and said they had developed close, friendly relationships with them and other people using the service. People were supported to maintain their independence and were supported to access activities of their choosing.
Care plans were person centred and focused on people as individuals. People’s preferences with regard to aspects of their care such as medicines, food and communication were recorded which meant that staff had access to information that enabled them to support people in a way that they wanted.
Staff told us they enjoyed working at the home, were given good training opportunities and felt well supported. They said the managers had an open door policy and were approachable
Risk assessments were carried out which helped to ensure that people were able to take part in daily activities in a safe manner. Behaviour management plans were in place for some people who displayed behaviour that challenged.
People received ongoing health care support and had health action plans and hospital passports in place. Staff responded to people’s changing needs and contacted the relevant health care professionals if people’s needs changed. People received their medicines safely and staff completed medicine records when they administered medicines.
People using the service praised staff for their dedication. They said, “Staff are very good”, “The staff are hardworking and praise worthy” and “The regular carers are excellent, they will try their best.”
Staff told us they were satisfied with the level of training that they received. The provider had implemented the Skills for Care Certificate for new staff and training records showed that staff received training in a number of areas that helped them to meet the needs of people using the service. Staff supervision was carried out every six-eight weeks and records were kept for any discussions that took place. Regular staff meetings were also held which meant that staff could raise any issues formally in a group setting.
Staff told us they were always careful to respect people’s wishes and ask for their consent. They demonstrated an understating of the Mental Capacity Act 2005 (MCA) and were included in best interest meetings and their opinion sought when applying for Deprivation of Liberty (DoLS) authorisations to restrict people’s liberty in order to protect them. The provider was in the process of applying for DoLS authorisations for some people living at the home where it was felt they were being restricted in some ways.
People were satisfied with the quality of food at the service and told us they were given a choice of meals to eat. They were given support with eating and drinking if they required it and guidelines were in place for staff to follow if they needed a modified diet.
People were supported to take part in activities of their choice and met with their key worker on a regular basis to discuss any concerns. Where people had raised formal complaints, the provider had guidelines in place to respond to them.
We saw that in some instances, although records such as risk assessments and goal monitoring were reviewed monthly, ongoing changes were not always recorded accurately. However, the registered manager provided evidence that they had amended both the risk assessments and the key worker meeting records so that changes could be recorded more clearly.
Heath and social care professionals were satisfied with the service that was provided to people and told us that staff and the registered manager were proactive and communicated well with them.
Quality assurance audits took place on a regular basis which included checks carried out by managers at another service, medicines audits, feedback surveys and incident monitoring. We saw that where issues had been found, the provider had taken action to rectify them.
We looked at a sample of care plans. These were person centred; people had contributed to them. These were reviewed every month and people were encouraged to attend the review meetings.
The home was split into different flats, staff told us that meals were planned and people helped with the shopping on a weekly basis. One person using the service told us "we have flat meetings where we discuss meals"; another person said "I love cooking". We saw evidence that a dietician was consulted to help with meal planning for people that required a modified diet.
We reviewed five staff files and saw that staff had supervision every three months and a yearly appraisal. We saw the training matrix for staff at the home and saw evidence that the provider had recorded people's training accurately and had identified gaps where training was overdue.
We asked for and received a summary of the formal complaints people had made in the past year and the providers response. People's complaints were fully investigated and resolved, where possible, to their satisfaction.
Relatives of people using the service spoke in positive terms about the care provided for their family members. One person told us "they provide extremely good care". We looked at six records of people using the service. The care plans also included risk assessments which were reviewed every month.
The provider had taken the appropriate steps in notifying the local authority and CQC of allegations of abuse. There was evidence that the provider had changed some of the policies and procedures in response to some of the concerns raised. The provider had gone to reasonable lengths to minimise similar concerns being raised.
We spoke with the manager about staffing levels at the home, they told us that rotas were produced a month in advance. We spoke with care workers about staffing levels. One person told us "things run smoothly" and "there is always someone available to cover".
Two surveys were sent out every year, one for staff and the other for residents and their relatives asking for feedback on the service. Relatives were also aware of how to raise a compliant of they wanted to.