St Marys Chanterlands Care Home

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. This is the first assessment for this newly registered service. This key question has been rated 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.

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.

Staff understood the importance of reporting concerns and had confidence in the registered manager to act appropriately when issues arose. Accidents, incidents, complaints and safeguarding concerns were recorded and reviewed. The registered manager led meetings to review incidents in the service. Learning was shared with staff via internal messages and wider team meetings to help improve the care and safety of people within the service.

The provider tried to work with people to establish continuity of care, including when people moved between different services. However, the provider did not always effectively evidence how they managed or monitor people’s safety. The senior leadership team had started to strengthen relationships with relatives and representatives to support safe pathways and transitions into the service. However, the provider could not always demonstrate how people's safety was effectively monitored and managed due to gaps in record keeping. Records did not consistently evidence that safety checks had been completed as required. Despite these concerns, we did not identify evidence that people had experienced harm. The provider responded immediately during the inspection to address this and improve their records.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

Staff worked with people and relevant partners to understand and manage safeguarding risks. Systems were in place to report and investigate safeguarding concerns, staff understood the reporting process, and the provider alerted external professionals when safeguarding incidents occurred. Relatives gave examples of the police, safeguarding teams and health professionals being involved following serious incidents. The registered manager demonstrated an understanding of their responsibilities when depriving an individual of liberty for safety purposes. Appropriate applications were in place as required to support the safeguarding of individuals. Relatives described being contacted when Deprivation of Liberty Safeguards authorisations were reviewed. Staff considered people’s capacity and involved representatives when people could not make particular decisions independently.

The provider did not always demonstrate effective systems were in place to manage risks. Records did not always reflect that staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People had risk assessments and care plans in place which reflected their individual needs and provided guidance for staff on how risks should be managed. However, records did not always demonstrate that risk management strategies had been consistently followed. We found gaps in records relating to safety checks, repositioning, dietary recommendations and the use of safety equipment. This meant the provider could not always evidence that care had been delivered in line with people's assessed risks and needs.

Despite these recording shortfalls, we saw that staff were knowledgeable about people's needs. We did not identify evidence that people had experienced harm because of the issues found. During the assessment, the provider responded promptly to feedback, agreed actions to strengthen oversight and recording processes, and took immediate steps to provide assurance that people were not put at risk while improvements were embedded.

The provider detected and controlled potential risks in the care environment. They made sure equipment supported the delivery of safe care. However, they did not always ensure the design of the environment met people’s needs.

The home was clean and tidy and equipment used had the required servicing certificates and was monitored on a regular basis for maintenance needs and safety. However, more work was needed to ensure the dementia unit reflected recognised good practice guidance that promoted people’s wellbeing and safety. For example, there was limited accessible signage within the unit. Visual contrasts to help people identify doors, bedrooms and toilets were lacking and people had minimal stimulation throughout the unit. The registered manager had raised these concerns before the inspection but improvements to the environment only began in response to inspection feedback.

The provider made sure staff were skilled and that they received effective support and development opportunities. Safe recruitment processes were followed, and staff received a through induction, with supervision and appraisal opportunities. Staff said they felt supported and worked well as a team. A staff member said, “I have enjoyed working at ST Mary’s so far and, overall have had a positive experience working as part of the team.”Training was provided to staff with monitoring in place to help ensure staff felt confident and skilled in their roles.

The provider used a dependency tool to determine staffing requirements. However, it was identified that on occasions, core night staffing did not meet the assessed staffing need recorded across the service, with additional cover provided through twilight shifts. Staff and relatives also raised concerns about staffing levels during evenings, nights and weekends, and the potential impact this could have on the quality and safety of care. While we had identified no measurable impact to people during the inspection due to this concern, it was recognised that the potential impact of unsafe care was a risk. The provider felt assured by their own staffing requirements however took feedback on board during the inspection and agreed to review this with staff.

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.People and relatives described the home as clean, and staff were observed using personal protective equipment appropriately. Domestic staff were present throughout the day and cleaning schedules and audits were in place. Although some gaps in cleaning records had been identified this was being addressed by the registered manager.

People received their medicines safely, and systems were in place for the safe storage, administration and monitoring of medicines. Staff were trained and assessed as competent, stock balances were accurate, and regular audits were completed. However, some areas of practice required improvement. Records did not always demonstrate the use of thickening agents for people with swallowing difficulties, temperature monitoring was not always completed in line with national guidance, and individual fire risk assessments were not consistently in place for people using paraffin-based skin products. While recording and oversight processes required strengthening, the provider acted quickly on feedback to rectify the record issues.