St Mary's Continuing Care

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 an increased risk people could be harmed.

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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. People, and their loved ones told us staff provided safe care. When incidents occurred, relatives were kept up to date and informed of actions taken to mitigate further risk. One relative told us, “The unit manager keeps me informed of any changes to their medication”. The provider had systems which focused on analysing and learning from events to help prevent future occurrences.

The provider did not always work well to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. We found inaccurate information in peoples care plans including important information such as deprivation of liberty assessments, preferences and inconsistent information. Staff demonstrated they knew people well and understood their needs, but we found evidence people’s care plans did not contain relevant information. Health professional we spoke with told us they worked with the service to meet people’s needs, and they were always open and worked in collaboration. Referrals were in place for services such as speech and language therapy (SALT), occupational therapy and GPs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider did not always work well with people to understand and manage risks. However, the care, staff did provide to meet people’s needs was safe, supportive and enabled people to do the things that mattered to them. Whilst risks to people’s personal safety had been assessed care plans did not always record the care needed to minimise these risks and keep people safe. For example, staff told us significant information about a person at the service which was not recorded in the care records. When we shared this with the provider, they took immediate action to update the care records.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment and equipment were kept in good condition, ensuring health and safety standards were consistently maintained. There was an up-to-date fire assessment for the service, and the recommendations had been actioned. Each person had a Personal Emergency Evacuation Plan (PEEP) which sets out detailed instructions about the level of support a person would require to evacuate the building in the event of an emergency. The fire alarm system was tested, and regular fire drills took place so staff could practice evacuation procedures. We saw valid certificates for legionella, gas safety, electrical safety and portable appliance tests.Staff received training, in health and safety, fire, first aid and moving and handling, and fire evacuations.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development opportunities. They worked well together to provide safe care meeting people’s individual needs. Staff recruitment processes were in place with relevant checks of staff’s employment history, character, right to work, and checks with the disclosure and barring service (DBS). Staff we spoke with were very committed and passionate about the work they did at St Mary's Continuing Care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Shared areas of the home as well as people’s own rooms were clean and tidy. The home was clutter free. Staff wore personal protective equipment (PPE) appropriate to their tasks. People were supported to maintain good hygiene. Staff knew about infection prevention procedures which they followed to protect people from risk.

The service did not always make sure the management of medicines was safe, and care plans did not always contain the required information to support staff to administer medicines safely. For example we found concerns around the administration of thickener to drinks increasing the risk of choking; When people had their medicines via a feeding tube, there was not always information from a suitably qualified healthcare professional to inform staff how to administer the medicines safely; When people were prescribed ‘when required’ medicines, information to support staff to know when to give the medicines was not always person centred, and in some records, we found contradictory information. This was a breach of Regulation 12, medicines. Following this inspection the provider gave assurances around administration and storage of medicines.