St Mary's Care Home

St Mary’s is a care home providing personal and nursing care for up to 54 people. The service provides support to older people, some of whom may have physical and nursing needs. At the time of our inspection there were 44 people using the service. The care home is an adapted building across two floors.

People’s experience of using this service and what we found

The provider’s governance system had not always been followed and actions were not always reviewed to make sure risks to people's health and safety had been fully resolved. There had been a number of changes to management which made it difficult to progress improvements. People had little opportunity for activities or social engagements.

People and relatives were positive about the caring nature of regular staff and had good relationships with them. There was a friendly culture in the home.

The provider tried to make sure there were enough staff to support people but there had been a lot of staff changes and the provider had to use temporary or agency staff too. Staff said there was not much time to spend with people but tried to make sure they were safe.

The premises had not been redecorated in some time and several areas were worn, dark or cluttered. The state of some bathrooms made them difficult to keep clean and some were odorous.

People said the meals were good and they were offered drinks and snacks at other times.

People were encouraged to retain their independence where possible, and their individual lifestyle preferences were respected.

People were supported to have maximum choice and control of their lives and staff assisted them in the least restrictive way possible and in their best interests; the policies and systems in the service upheld this practice.

People, relatives and staff said the new manager was open and approachable. Overall, relatives said people were well-cared for at the home. Relatives said there was a lot of issues to resolve at the home but they were hopeful the new management arrangements would address them.

Following our visits to the service, we asked the provider to send us an improvement plan detailing what actions they would take in relation to the issues identified during our inspection.

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 21 January 2020). 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 the provider remained in breach of regulations.

Why we inspected

This inspection was prompted in part due to concerns received about the management of the service. A decision was made for us to inspect and examine those risks.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Mary’s on our website at www.cqc.org.uk.

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 person-centred activities and the governance of the service. We have made recommendations about the timeliness of staff support at mealtimes and refurbishment planning.

Please see the action we have told the provider to take at the end of this report.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice during our inspection:

¿ Systems were in place to prevent people, staff and visitors from catching and spreading infections.

¿ People and their relatives were supported to keep in contact using a range of technology.

¿ Additional cleaning of all areas and frequent touch surfaces was being carried out regularly.

¿ People were supported to understand the pandemic and the need for infection prevention and control (IPC) measures, such as staff wearing face masks.

¿ People and staff participated in a regular testing programme.

¿ Appropriate vaccination status checks were in place.

¿ Staff wore appropriate PPE and the service had ample PPE supplies.

St Mary’s Care Home provides accommodation for up to 54 people with residential and nursing care needs. At the time of the inspection, 35 people were using the service.

People’s experience of using this service and what we found

At the previous inspection, we made two recommendations. These were to improve the environment for people living with dementia and to review planned activities. Not enough improvement had been made in these areas at this inspection. Improvements were needed to make the environment more suitable for people living with dementia. There was a lack of planned, person-centred activities. Activities records were inconsistently completed and people told us there wasn’t a lot to do.

People and family members told us the service was safe. Risks were well managed and the provider learned from previous accidents and incidents to reduce future risks. Arrangements were in place for the safe administration of medicines.

There were enough staff on duty to meet the needs of people. The provider had an effective recruitment procedure and carried out relevant checks when they employed staff. Staff were suitably trained but supervisions and appraisals were inconsistently carried out.

The home was clean and appropriate health and safety checks had been carried out.

People were effectively supported with their dietary and healthcare needs. One person who had been admitted with pressure damage did not have a skin integrity care plan in place and the body map contradicted the written record. The nurse on duty corrected this during our visit.

Staff treated people with dignity and respect. They helped to maintain people’s independence by encouraging them to care for themselves where possible.

People were supported to have maximum choice and control of their lives, and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

The provider had a complaints policy and procedure and people were aware of how to make a complaint. People, family members and staff were regularly consulted about the quality of 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

The last rating for this service was good (published 9 May 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified two breaches in relation to lack of improvements made at the service following the last inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Following the last inspection of St Mary’s Care Home on 18, 19 and 25 October 2016 we reported that the registered providers were in breach of the following:-

Regulation 9 Person Centred Care

Regulation 12 Safe care and treatment

Regulation 14 Nutrition and Hydration

Regulation 17 Good governance

We asked the provider to take action to make improvements and found during this inspection improvements had been made.

There was 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.

People were being given their medicines in a safe manner. Staff were patient and kin as they explained to people what their medicines were for. We found medicine records were up to date with no gaps. People’s topical medicines (creams applied to the skin) were being administered as prescribed.

Staff recruited to the service had undergone a number of checks to ensure they were suitable to work in a care home.

Regular checks were carried out on the building including fire checks, window restrictors and bed rails to make sure people were safe living in the home.

The service met the requirements of the Mental Capacity Act and the Deprivation of Liberty Safeguards. This meant staff had applied to the local authority to deprive people of their liberty and keep them safe.

The home had recently been decorated and there was some signage to help people orientate themselves around the building. We recommended the provider review the home in the light of recent research and guidance to develop a home where the needs of people living with dementia could be met.

We found staff were provided with support through induction, training and supervision, and saw since our last inspection staff had updated their e-learning.

The service had used the Herbert Protocol. This is a nationally recognised scheme where people who are at risk of going missing are registered so that their details can be immediately released if they go missing again.

Staff were aware of people’s histories and family members. They were able to engage people in conversation with humour. We found staff treated people with respect and dignity and personal care was carried out behind closed doors.

The service did not employ an activities coordinator. Staff had been advised to provide activities as well as carrying out their other duties. We saw staff were doing this however we found improvements could be made to coordinate activities, and encourage and support people in their individual hobbies and interests.

Since the last inspection people’s care plans had been brought up to date. We found they were accurate and reflected people’s individual needs. They included plans for people who had specific diagnosed conditions and additional information had been provided to staff about the conditions.

We found staff had improved their use of food and fluid charts and understood the importance of hydration. This meant people were no longer at risk of becoming dehydrated without staff taking actions.

The registered manager was able to tell us about the service and provide the information we needed to conduct the inspection.

People who used the service, relatives and staff were complementary about the effectiveness of the registered manager.

The registered manager had developed new initiatives in the home to ensure people received the care they needed and staff were competent in their role. This included a weekly review of people’s care needs and ensuring staff knew how to appropriately thicken people’s drinks when they were at risk of choking.

At our last inspection of St Mary’s Care Home in May 2016 we reported that the registered providers were in breach of the following:-

Regulation 9 Person Centred Care

Regulation 12 Safe care and treatment

Regulation 15 Premises

Regulation 17 Good governance

Regulation 18 Staffing

The overall rating for this service was 'Inadequate' and the service was placed in 'Special measures'. This is where services are kept under review by CQC and if immediate action has not been taken to propose to cancel the registered provider's registration of the service, the location will be inspected again within six months. The expectation is that registered providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following the last inspection in May and June 2016 the registered provider sent us an action plan and provided us with regular updates.

At this inspection we found there were some improvements. However we also found there were further continued regulatory breaches.

There was not registered manager in post when we visited the home and there had not been a registered manager there for the previous 18 months. 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. The service had appointed a new manager who had applied for their Disclosure and Barring Check for their CQC registration process.

Medication administration procedures and systems were not robust and did not protect people living at the home from risk associated with poor medicines management. We found that the administration of medicines at the home did not follow best practice guidance.

We found that checks to verify staff’s employment history were not carried out appropriately.

Chemicals being used at the home including professional type cleaners containing ingredients which were likely to cause injury if accidentally splashed or consumed did not have corresponding suitable information which could be used to promote safe storage and which could be followed in an emergency. Immediate steps were taken to improve safety once it was drawn to the attention of the provider.

We found improvements had been made where staff were now routinely recording people’s fluid intake. But where this was low, no actions were put in place to address the issue. This meant people continued to be at risk of dehydration. The registered provider had also failed to ensure that some people’s dietary requirements were accurately recorded in care files and this information was shared with catering staff. This posed significant risks to people’s health and well-being.

The registered provider was not doing all that was practicable to keep people safe because some unoccupied bedrooms which contained dangerous items could have caused injury to people living at the home, staff or visitors.

The manager had appointed two staff as ‘dignity champions’ for the home. However we saw an example where a person’s dignity was compromised.

We found examples where care plans gave incorrect or insufficient information to promote effective care or guide staff practice.

We found peoples care needs had not been reviewed when they moved back to the home from hospital where they had developed additional complex nursing and care needs.We found a number of examples where the service had not responded appropriately or in a timely manner to people’s urgent nursing care needs. This included where people had specific conditions, required end of life care or skin pressure care issues. This included an instance where a GPs had recommended a follow up visit from a specialist nurse but the registered provider had failed to put this in place.

The registered provider did not meet the NICE guidelines in supporting people with dementia to take part in leisure activities during their day based on individual interest and choice.

At the last two inspections we found people's records were not stored securely. During this inspection we again found the same cupboard used to store people's old records was again unlocked. This meant people's archived personal records were not stored securely and the manager and registered provider had failed to improve previous breaches of the regulation.

We saw some audits [monitoring checks] had been put in place since our last inspection but monitoring had failed to identify significant omissions in the provision of care. We did not find a planned and structured system at the home which would routinely assess, monitor and improve the quality and safety of services and mitigate risks.

We saw the manager had held meetings with relatives to seek their views. The manager had sent surveys to relatives and was awaiting their return.

Visiting professionals told us staff worked with them in partnership to meet people’s needs.

We saw staff using moving and handling equipment and throughout helping people to move they provided them with explanations, encouragement and support.

Since our last inspection the registered provider had taken action to improve accident reporting.

We looked at the staff rotas and found the numbers of staff on duty were as described to us by the manager and no staff members had been transferred to another home to work whilst remaining on St Mary’s rota.

Checks had been carried out on the building to ensure people we safe. There was a current fire risk assessment in place. Agency staff had been given instructions in the use of the emergency fire prevention / alarm equipment.

The registered provider had in place a whistle-blowing policy which explained to staff how to tell someone about worries they may have about the home.

The home was clean and tidy; cleaning was on-going during our inspection and staff were able to describe to us what actions they carried out during their cleaning to reduce the spread of infections.

We found the manager had carried out a supervision of all of the staff. Supervision is a meeting which takes place between a member of staff and their manager to discuss any concerns they may have, their practice and their training needs. Staff had also recently had their training updated.

The provider had made applications to the required authority to deprive people of their liberty when they considered it to be in their best interests. We spoke with the manager about the Mental Capacity Act 2005 [MCA] and Deprivation of Liberty Safeguards [DoLS] and found they understood the requirements of both.

During our inspection we found a number of breaches of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014.You can see what action we told the registered provider to take at the back of the full version of the report.

Details of any enforcement action taken by CQC will be detailed once appeals and representation processes have been completed.

At the last inspection on 1 and 2 September 2015, we rated this service as ‘Inadequate’. We served warning notices on the service and asked the registered provider to take action to make improvements, for example, on people’s topical medicines, staff supervision and documentation. The registered provider put in place an action plan to improve the service.

At the time of our inspection there was not 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. St Mary’s Care Home is owned by Carewell Healthcare Limited. One of the partners of Carewell Healthcare Limited employed a regional manager for other services provided by them. This regional manager had offered support to the manager of St Mary’s Care Home and was present during the inspection.

People who used the service and their relatives were complimentary about the staff. Staff displayed caring qualities towards people and treated them with kindness and respect.

We found the service met the requirements of the Mental Capacity Act 2005 (MCA) and had made applications to the appropriate authority regarding the Deprivation of Liberty Safeguards (DOLS).

The service had received a certificate from the initiative, “Focus on Undernutrition" in care homes. Staff confirmed to us they had completed the training. The initiative uses the Malnutrition Universal Screening Tool (MUST) which gives recommendations about people’s nutritional requirements if they are at risk of malnutrition. We found the home had not followed the requirements. Staff were not aware of what snacks were available for people who were diabetic.

The service had put in place fluid charts for people. We found staff had recorded the amount of fluid they were giving to people but not the amount they had actually drunk. The fluid amounts had been totalled; however there were no target fluid amounts in place. Staff therefore were unable to assess if people were at risk of dehydration. By 2 June 2016 the manager had begun to put in place target fluid levels. On 17 June 2016 we found information for staff had been put in people's files from Association of UK Dieticians regarding hydration including meeting the needs of older people.

We found Medication Administration Records for people’s prescribed topical medicines had not been completed. We also found there were no dates of opening on people’s topical medicines and topical medicines had not been destroyed in line with the manufacturer’s guidance. Following our visit on 26 June 2016 the manager had put in place a new system to manage people's topical records, however we found the system was not always adhered to.

The management team told us staff provided activities for people each afternoon. Staff told us they were not always available to do this as they were often called away to carry out other duties. During our inspection we saw staff had put a film on the television for people who were then left unsupervised. We found staff were not deployed to provide appropriate supervision of people.

Staff had received training in safeguarding and were able to tell us what actions to take if they had concerns about anyone using the service.

We looked at 10 people’s care records and found they contained personalised information to enable staff to provide appropriate care of people. However not all of the records gave staff guidance to manage the risks to people.

Staff had not received supervision in line with the registered provider’s policy. This meant the service had not provided staff with meetings with their manager to discuss any concerns and their personal learning needs.

We found records in the home were at times inaccurate or they were not up to date. This meant we could not always be assured that people’s care needs were being met.

The home had in place handover information between nursing staff and care staff. We found the handover information to an agency nurse who was on duty at the time of our inspection was inaccurate and if the information had been followed for one person it would have put them at risk.

We found the service had in place a number of quality audits to measure its performance. The manager then drew up a remedial action plan for each month. However, we found some of these audits were undated and the audits did not tell us what records had been checked by the manager. We found the audits did not address the deficits we found in the service.

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were protected from the risks of unsafe or inappropriate care and treatment because their records were securely maintained and they were protected against the risks of unsafe or unsuitable premises.

People were not protected against the risks of unsafe use or management of medicines because the provider did not have appropriate arrangements in place to safely manage them. We have judged that this has a major impact on people who use the service and have taken enforcement action against this provider. Please see the 'Enforcement action' section within this report.

Effective recruitment and selection processes were not in place. Appropriate checks were not undertaken before staff began work.

Is the service effective?

People's health and care needs were assessed with them, and they or their representatives were involved in writing their plans of care. Specialist nursing, dietary, social, mobility, equipment and dementia care needs had been identified in care plans where required. People and their relatives said they were happy with how their needs were being met.

Is the service caring?

People told us they were supported by kind and attentive staff. We saw care workers showed patience and gave encouragement when supporting people. One person said the care staff 'were marvellous' and they 'treated him with the respect he deserved.' If I'm not happy everyone knows they can make a complaint to the management - and we would.' Another person said 'You couldn't want for any better, the staff treat you like a human being and they really care about us.'

People's preferences, interests, aspirations and diverse needs were recorded and care and support was provided in accordance with people's wishes.

Is the service responsive?

People who lived at the home and their relatives felt the staff and manager were approachable and we saw how they were able to talk freely, ask questions and were satisfied with the responses given.

Is the service well-led?

The service worked with other agencies and services to make sure people received their care in a joined up way.

However the checks to make sure people were protected against the risks of unsafe use or management of medicines and checks of recruitment information for new staff were not robust and placed service users at risk.

We found care and treatment was planned and delivered in a way which ensured people's safety and welfare. One person who lived at the home told us, 'I'm happy, I'm properly looked after there's nothing I can think of they're not doing.' Another person said, 'From getting up to going to bed they look after me well.'

We found effective measures were not in place to protect people from the risks of unsafe use and management of medicines.

We also found the provider had not taken steps to provide care in an environment that was adequately maintained.

The provider had taken steps to make sure people at the home were protected from staff who were unsuitable to work with vulnerable people by carrying out thorough background checks.

We found people who use the service were not protected against the risks of unsafe or inappropriate care because their records were not securely maintained.

We did not record comments from people who were using the service or visitors as this was a follow up inspection.

When we visited we found there were effective systems in place to protect people from the risk and spread of infection because appropriate guidance had been followed.

We looked at the way equipment was used at the home. We found people were protected from risks of unsafe or unsuitable equipment because the provider had taken steps to make sure they were used and maintained properly.

We found the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and promote their health and wellbeing.