St Mary's Nursing 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 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.

At our last inspection the provider was in breach of the legal regulations in relation to people’s safe care and treatment and the management oversight of the service. Improvements were found at this assessment, although there remained some areas for further improvement.

This service scored 62 (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.

The provider was committed to identifying learning and making improvements. Overall, the provider’s systems around learning from incidents were effective. New systems and processes had been introduced to make improvements.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider recognised the value and importance of working with partners to improve staff knowledge and understanding of local systems and how people transitioned through them. The provider’s representatives attended regular meetings with partners to provide updates on improvements and developments in the service. The provider had put in place a reporting system which enabled them to review call bell response times.

Overall, the provider made sure there was continuity of care, although there remained room to improve some people's care plans to ensure there was clarity of information, including when people moved between different services.

We asked people what their experience of the admission process was and if they were involved in developing their care plans and care plan reviews. One person, who regularly came to the home for respite care, said, “Yes I am safe, the staff are alright with me. Each time I have come they have always been good with me.”

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. There was a safeguarding log in place. Themes, trends and learning were identified and used to improve the quality of care and support

The care consultant and staff we spoke with demonstrated a commitment to safeguarding people and understood the principles of keeping people safe.

Overall, people’s feedback positive. One person said, “I am safe with the staff.” A visiting relative said, “Yes, [my family member] is safe here, otherwise I would move them.” Another relative said, "Yes, it’s safe. You always see someone around and they always talk to me as well.”

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.

People’s risk assessments, care plans and daily records had been revised and improved, although there remained room for further improvement for some people. Care plans were in the form of a running log and, although some were highlighted to help staff to see the most recent entries, this was not always the case.

Where people were at risk of developing pressure sores, their plans included directions for staff to undertake daily checks of their skin integrity. These checks were not documented by staff., therefore it was unclear if they were taking place.

A nurse told us mattress checks were completed weekly and we saw evidence that checks had been completed. However, 1 person’s mattress was on an incorrect setting for their weight and this had not been identified by the provider’s checks and audits. We saw no evidence people had come to harm, however, the lack of assurance that pressure mattress settings were correct and the shortfalls in records in relation to checks of people’s skin integrity increased the risk of people developing pressure damage. This is addressed under the Well-led section of this report.

People told is they felt safe in St Mary’s Nursing Home. One person was nervous about other people using the service coming into their bedroom and they told us, “I ring my buzzer and the staff come if I have a problem.”

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. Overall, people were happy with the environment. People’s comments included, ”I like my room. I can see out the window to the field and the sun rise and sets are beautiful. I am used to it here.” and “The room is nice and it is clean. I am alright here.” A relative said, “I asked them if [my family member] could move rooms. This is a lot lighter, bigger and nicer for [my family member].”

The home was under a fire enforcement notice from South Yorkshire Fire and Rescue Service, and we saw changes and improvements had been made to ensure compliance and safety. The emergency lighting had been replaced and new fire extinguishers and fire doors had been purchased. We received confirmation all works had been completed so the provider was compliant with fire safety regulations.The care consultant understood the need for a safe environment and improvements were being made to ensure compliance with a recent enforcement notice issued by the local Fire and Rescue Service.

Processes were in place to make sure repairs needed to the premises were escalated to the appropriate people, either maintenance staff on site or external contractors, to help ensure people’s health and safety was maintained. Improvements had been made to the environment and were on-going. There remained some aspects of the care environment that needed attention. For instance, a safety gate at the top of a staircase was not tall enough, and there was no documented evidence to show weekly visual checks of equipment, such as wheelchairs, was taking place. Fire drills were taking place but it was unclear if nighttime drills were included planned evacuation practices. We discussed these areas with the care consultant, who took immediate action to address them.

The provider did not always make sure there were enough qualified, skilled and experienced staff. We saw staff were available throughout the building but not always visible and supporting people on every floor. We discussed staffing with the care consultant who undertook to review the way staff were deployed.

Most people and relatives we spoke with said there were not enough staff to make sure people received the care they needed. One person said, “They don’t have enough staff. I can’t move out of my bed and if there aren’t enough staff to get me into my chair I have to stay here.” Relatives reflected this view. One relative said, ”Staff morale is a bit low. They need more staff to help people to eat their breakfasts, as there are a lot of people in bed.”

Staff were recruited safely. The provider completed pre-employment checks such as references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

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.

Overall, the shared areas and people's rooms were clean. however, there was a need to redecorate and refurbish some areas. Staff received training in infection prevention and control, and we saw staff using and disposing of personal protective equipment appropriately.

Most people and relatives felt the home was clean, but some people felt the domestic staff were over stretched. Feedback included, ”The cleaning staff are perfect. They wipe down the surfaces and floors. They do it regularly, they change my bed every day and in-between times when I need it. They are part of the care home family, but I think they [domestic staff] are too busy and stretched.” A relative told us, “It’s clean here. [My family member’s] room has been done this morning.”

Policies, systems and processes were in place to monitor how the service managed infection prevention and the care consultant told us work was ongoing to sustain improvement and promote good infection control.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Overall, people were happy with the support they received with their medicines. However, some people and relatives told us when staff were busy, it sometimes took a long time for staff to provide people with pain relief. For instance, a relative said,“[My family member] can ask for pain medication. It varies, sometimes [staff] come quickly and other times it can be up to 30 minutes.”

There were policies and procedures for administration of medicines and staff were trained in the safe handling of medicines. The staff we spoke with did not identify any concerns about the management of people’s medicines. People had protocols in place for ‘as and when required’ medicines. These helped staff to know how people might indicate when they were in pain if they were unable to communicate verbally.