6 December 2023
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
The inspection team consisted of 2 inspectors and an 'expert by experience'. An 'expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
St Marys is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. This included feedback from the local authority and professionals who work with the service. The provider was in the process of completing the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to prepare our inspection.
During the inspection
We spoke with 12 people who used the service and 4 visiting relatives. We reviewed the care records of 4 people who used the service. We also reviewed a range of records relating to the management of the service, including audits, policies and procedures, staff training, 4 staff files and recruitment records. We spoke with 4 staff members as well as those who facilitated us, such as the registered manager, administration person and district manager.
Following our inspection visit, we received electronic records and gave initial feedback remotely and in writing.
6 December 2023
About the service
St Marys provides residential care for up to 60 people. At the time of our inspection there were 51 people living at the home. The home is split in to two areas. The area of the home known as Constable was supporting 23 people living with dementia. The remaining rooms in the main building were known as Gainsborough and Waterhouse.
People’s experience of using this service and what we found
People benefited from a well-designed and maintained care home with accessible gardens. People were supported by a staff group who were committed to providing high quality care and support. Staff were visible and available to people. Staff demonstrated kindness and caring values in their approach to people.
Systems were in place to safeguard and mitigate risks of abuse and avoidable harm. People received their medicines when they needed them. Lessons were learned when things went wrong, and measures put in place to reduce the risks of them happening again. Staff were trained in infection control and used personal protective equipment where required.
Ongoing recruitment meant there were enough staff to ensure people were provided with the care and support required to meet their assessed needs and staff were recruited safely. Staff were trained to meet the needs of people. Where people required support with their dietary and health needs, this was assessed and systems in place to meet their needs.
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.
People’s care plans were person centred provided guidance for staff in how their assessed needs and preferences were met. People received care and support from staff who were caring and who respected their privacy and independence. People made decisions about their care and support, including how they preferred to be supported and their end-of-life decisions.
Systems were in place to monitor and assess the care provided, and where shortfalls were identified actions taken to make improvements. There was a complaints procedure in place and people’s views were used to improve the service. The service worked well with other professionals involved in people’s care.
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 27 January 2018).
Why we inspected
We undertook this inspection to check whether the service was continuing to provide a good rated service to people due to the age of the last rating.
The overall rating for the service remains good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Marys on our website at www.cqc.org.uk.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.