St Mary's Residential 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

Lessons were not always learnt to continually identify and embed good practice.

Incidents were appropriately reported internally in the service. However,improvements were required to ensure the leadership team consistently identified and embedded lessons learnt from incidents at the service.

There was limited evidence of a learning culture within the service from incidents. Staff were not always able to learn from incidents or concerns because the leadership team did not have clear procedures in place to support reflection, improvement and accountability.

St Mary’s Residential Home was currently being supported by the nominated individual and a consultant due to awaiting the start of a new manager.

The leadership team was responsive to our findings and held a staff meeting during our inspection which reflected recent incidents and how lessons learnt would be developed at the service.

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.

People were supported in accessing appropriate healthcare professionals for their health needs. For example, people were receiving support from GPs, district nurses, falls team, SALT (speech and language therapist) and dietitians.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

During our assessment an incident had been reported of a person who had sustained unexplained bruising on their face. The service did not investigate fully or make a referral to the safeguarding team.

When we raised our concern to the leadership, they reviewed the incident and referred to the safeguarding team.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

For example, we found staff had not always sought further immediate medical advice following people’s falls.We found one person who had a fall and banged their head, staff-maintained observations but did not seek further medical advice.This put people at risk of harm, we found no one had been harmed.

However, the leadership team was developing staff awareness in the procedure of supporting people following witnessed or unwitnessed falls.

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.

During our inspection we found gas cylinders were not stored securely in the garden, the use of stair gates had not been risk assessed and a fire escape had ahigh-level bolt which could not be reached by all staff in the case of evacuation.

The nominated individual was proactive in addressing the concerns which we raised.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had a structured rota system and a dependency tool which supported the staffing levels required to support people’s needs in the service.

Staff told us that there were appropriate numbers of staff on duty to meet people’s needs.

A relative told us, “There are enough staff and they are very caring.”

Staff had received appropriate training to carry out their roles in supporting people at St Mary’s Residential Home. We observed staff working as a team to support people’s needs.

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.

During our inspection we found aged, stained urinal bottles in use for people. We informed the leadership team who actioned our concern promptly.

The environment was aged in part; however, we observed the home to be maintained and clean. Staff had completed training in infection, prevention and control. We observed staff using personal protective equipment (PPE) appropriately when supporting people with their needs.

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.

We found not all people using emollient creams had risk assessments in place. Staff we spoke with understood the precautions required in the use of emollient creams.

Sufficient systems were in place for safe and effective medicines management. The provider made sure medicines and treatments were safe and met people’s needs. Medicines were stored securely, and records of medicines held by the service matched the stock levels when we checked. People with ‘as and when required’ (PRN) medicines had protocols in place which were reviewed regularly.

Staff that administered medicines had completed safe management of medicines training and had under gone an assessment to check their competencies to administered medicines safely.