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Archived: St Mary's Inadequate

Inspection Summary

Overall summary & rating


Updated 25 January 2018

We undertook an unannounced inspection of this service on 27 July and 2 and 9 August 2017.

St. Mary's is a large detached property providing residential and dementia care for up to 36 older people. The service is located within the town of Dover. Residential accommodation is situated over four floors. There is a separate unit to support people living with dementia. The service also has its own chapel and a garden to the rear of the property. At the time of inspection there were 21 people living at the service.

This service did not have a registered manager in post. The previous registered manager left the service in April 2016. At the previous inspection the provider told us that they were in the process of appointing a new manager but this had not been done. A registered manager from the provider’s other location was supporting the service two days a week and there were two deputy managers in day to day charge of the service. The two deputy managers supported three inspectors during the first day of the inspection. A registered manager is a person who is 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.

We last inspected this service in January 2017. We found significant shortfalls and the service had an overall rating of requires improvement with an inadequate rating in the well led domain. The service had been rated ‘inadequate’ overall at our inspection in August 2016 and been placed in special measures. As the provider remained in breach of the regulations and there was a lack of leadership the service remained in special measures which required the provider to make improvements. Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. The provider sent us information and records about actions taken to make improvements following our previous inspection.

At this inspection improvements had not been made and the provider had not complied with all of the requirement notices issued at the previous inspection in January 2017 and further breaches of the regulations were found at this inspection.

The provider had failed to comply with a condition we had applied to their registration requiring them to appoint a registered manager. Although some efforts had been made to register a manager and an application had been sent to CQC this was subsequently withdrawn.

The systems in place to audit the quality of the service were not effective. The provider had not ensured that the requirement notices issued at the previous inspection were complied with. There remained continuous breaches of 5 regulations and 6 further breaches of regulations were identified at this inspection.

Whistle blowers had contacted the Care Quality Commission to inform us that staff were getting people up in the dementia unit from 5 am onwards. We arrived at 7 am; four people were up in the dementia unit and two people were up in the residential unit. Action had not been taken to address this concern and to make sure people had the choice of when they wanted to get up.

People were not protected from harm as the provider had failed to take action to ensure people were safe and report safeguarding issues to the local authority.

Risks to people’s health when they fell were not being mitigated and there continued to be a lack of risk assessments to guide staff how to support people safely. People were at risk of choking however, detailed risk assessments were not in place to ensure that staff had information to support people with their meals and drinks.

People sometimes displayed behaviour that challenged and were at risk of harming themselves or others. The deputy manager had implemente

Inspection areas



Updated 25 January 2018

The service was not safe.

People were not protected from harm as the provider had failed to take action to ensure people were safe and report safeguarding issues to the local authority.

Risks to people's safety and behaviour were not always managed. Staff did not always have the guidance to support people safely.

Accidents and incidents had been recorded but further analysis was required to keep people safe and to reduce the risk of further events.

The management and storage of medicines was not safe.

There was not always enough staff on duty to meet people's needs and staff were not recruited safely.



Updated 25 January 2018

The service was not effective.

Staff did not have a full awareness of the Mental Capacity Act and Deprivation of Liberty Safeguards as they had not recognised when people�s liberty had been restricted.

People had access to health care professionals when needed, however referrals had not been followed up to ensure people were receiving the professional advice they needed.

People received enough to eat and drink to support them to remain as healthy as possible.

Staff had received training, supervision and appraisals to support them in their role.


Requires improvement

Updated 25 January 2018

The service was not always caring.

Staff treated people with respect however, the provider had not treated people in a respectful way..

People were encouraged to be independent where possible and were given choices about their care and support.

People and relatives told us that the staff were kind and caring.

People�s personal information was not always stored securely.



Updated 25 January 2018

The service was not responsive.

People�s care was not personalised to ensure consistent safe care was being provided. Although care plans were regularly reviewed the information was not always updated to reflect people�s current needs.

There was lack of meaningful activities and no formal programme to ensure that people were able to maintain their hobbies and interests.

Complaints had not been recorded and complaints had not been investigated and resolved, or responded to appropriately.



Updated 25 January 2018

The service was not well led.

The provider had not appointed a registered manager to improve the leadership of the service.

The provider had not taken appropriate action to ensure the service was compliant with the regulations.

The systems for monitoring and checking the quality of care provided were not effective as the shortfalls found at this inspection had not been identified and actioned.

People/relatives and staff views were not taken into account to continuously improve the service.

Records were not always accurate or up to date.