St Marys

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 their responsibilities to record and report any accidents or incidents. The registered manager implemented systems to ensure accidents and incidents were regularly analysed to identify any emerging themes or patterns to mitigate further risks and improve the care provided. Records showed that learning from events had been cascaded through the staff team and staff were informed on how risks were managed.

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.

Assessments were completed before people moved into the service. There were systems in place to facilitate safe transfers for people between care services. People’s needs were assessed using information obtained from other health and social care professionals, relevant representatives and the person themselves. Care plans provided guidance to staff on how best to support the person. Staff followed instructions safely and effectively working closely with external professionals, such as the mental health team, occupational therapists, pharmacists, district nurses and the GP to ensure people received safe care and treatment.

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 had safeguarding systems and processes to ensure compliance with statutory requirements and protect individuals from abuse and neglect. Safeguarding records were maintained, documenting all incidents and the corresponding actions taken to mitigate future risks. These actions included notifying the local authority safeguarding team and updating the individual’s care plan in line with best practice.

Staff had completed safeguarding training and understood how to report concerns about abuse or neglect. This included raising concerns within the service and, if needed externally to relevant stakeholders. A staff member said, “I know how to report anything I feel is a safeguarding to my line manager, the local authority safeguarding team, CQC or the police.”

People can only have their freedom restricted for care and treatment if there is a legal process in place. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005. The provider regularly checked and monitored these safeguards. Each person’s care plan included details about their capacity and any DoLS in place, explaining what this meant for their support. When people needed help to make decisions, staff recorded how choices were made in the person’s best interests.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff knew people very well and supported people to manage risk while maintaining their independence and the service promoted positive risk taking. For example, people were assessed for risks related to diabetes, catheter care and mobility. Relevant support and equipment were provided, where required, to help minimise potential risks. Care plans contained information about people’s preferences and views in relation to decisions about risk.

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 design of the premises was safe and met people's needs. The provider was investing in the service with planned improvement works to the building and outside areas planned for 2026 underpinning the continual development of the service.

The provider’s systems assessed and maintained the environment and equipment used, for example, fire alarm system, portable appliances and gas safety. Checks and audits were also carried out on water safety, call bells and regular fire drills were conducted. One person told us, “I feel very safe here, we have plenty of locks on the doors, the fire alarm is scheduled regularly.”

People had their own bedrooms which they personalised with furniture and belongings. People had equipment they needed to help keep them safe, such as wheelchairs, walking aids, and bath and shower equipment. These were regularly checked to make sure they were fit for purpose.

People had personal evacuation plans to ensure staff evacuated them safely in an emergency.

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.

An established staff team who knew people well and how to meet their needs was in place; turnover was low and with zero reliance on agency staff. Staff were recruited safely, with appropriate pre-employment checks carried out before they started working at the home which included Disclosure and Barring Service (DBS) checks. Staff had received appropriate training to enable them to safely carry out their roles, and they received regular supervisions and appraisals. There were opportunities for staff to professionally develop including undertaking relevant qualifications within the care sector.

On the day of the inspection, we observed suitable staffing levels. People’s requests for care and assistance were responded to in a timely manner. Feedback about staffing levels was mixed. Some people and relatives told us there was enough staff to respond to people promptly. One person said, “I see staff all the time, nights are similar to days, just less staff, we have alarms (call bells/pendants) and if I buzz at night they come reasonably quickly, same in the day.”

However, some people, relatives and staff told us of challenges when staff struggled on occasions when trying to respond to requests for assistance, alongside carrying out meaningful engagement through activities. A relative said, “Staff can be a little stretched in the dementia unit if a number of residents are calling on their time all at once.” Another relative shared, “Staffing is always a challenge in any care home. Staff at St Marys are no different. They are often rushing around and stretched for time. They manage all the necessary tasks but there is less time for the more emotional support some residents need. This I think gets lost amongst the challenges of delivering food, drinks, washing etc; the more practical tasks.”

The provider did not have a designated activities lead or team in the service to coordinate or deliver 1:1 or group engagement and encouraged a ‘whole home approach,’ whereby all staff were involved in meeting people’s cognitive, social, emotional and wellbeing needs. There were also external visitors to the service for planned events and scheduled activity sessions taking place throughout the week.

During our inspection we shared instances we had observed where people were left for periods with no designated activity taking place, just the television on in the background, and without stimulation they had fallen asleep. This was a missed opportunity to meet the cognitive, emotional and wellbeing needs of people especially those living with dementia.

The registered manager and provider were receptive to our feedback and advised they would review their existing activities provision and staffing arrangements, including the organisation and deployment of staff and strengthen their processes for people cared for in bed who could become at risk of becoming withdrawn and isolated.

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.

The environment and equipment were clean, and risks associated with infections were assessed and well managed. There were regular checks and audits of cleanliness and hygiene. Staff had received training in infection prevention and control, health and safety, and food hygiene.

Staff followed several measures to promote good infection prevention. Housekeeping staff maintained a consistent cleaning schedule of all areas of the service, and we observed cleaning tasks being undertaken throughout our inspection in line with best practice. A staff member shared, “There are strong infection control processes in place. Staff follow hand hygiene procedures, regular cleaning schedules are maintained, and we use personal protection equipment (PPE) appropriately according to the care tasks we are performing. We have sufficient PPE available, and stock levels are checked regularly to make sure we never run low.”

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.

People’s medicines were administered safely. People told us they received their medicines when they needed them. One person said, “I have my medicines twice a day, [staff] stay until I have taken them, it’s around the same time [each day], and none are missed.”

We observed good practice when staff were administering people’s medicines. Staff explained the medicine being providing and ensured people had access to a drink and were not rushed.

Electronic systems, including auditing processes, supported the safe management of medicines, and leaders demonstrated good oversight and compliance with legal frameworks. Medicines were regularly checked and stock levels tallied, and PRN protocols were consistently followed. Staff received training and induction in medicines management, with ongoing competency assessments. Senior staff carried out regular audits to ensure compliance with procedures.

An external medicines audit had been carried out and an action plan produced as a result. This had been shared with staff who administered medicines, so they were aware of action they needed to take.