St Mary's Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people’s needs were met through good organisation and delivery.

This service scored 64 (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 did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People had personalised care plans and tools in place, such as communication passports and activity planners, which described how they preferred to be supported. Staff and relatives told us staff were kind and knew people well. One relative said “[Named person] looks fine. Staff are all very kind.” Another told us, “[Named person’s] happy to be there. They take good care of him.” However, we also saw examples of task‑focused care, especially during busy periods, where people were supported but not always in a personalised way. Some care records also lacked clear best‑interest decision‑making, person‑centred goal setting or up‑to‑date information on health needs. While many people experienced warm, individualised support, further and sustained improvement was needed to ensure that person‑centred approaches were reliably embedded across all staff, shifts and records.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

There was evidence of coordinated work with external professionals, including learning disability intensive support teams, social workers, speech and language therapists and district nurses, who provided advice on communication, mental health, dietetics and care planning. Relatives told us they were generally informed when required and felt staff acted when concerns were raised. Staff also demonstrated good awareness of changes through handovers and regular clinical meetings, with rotas planned and monitored for safe coverage.

Important health information was sometimes missing in records, such as outcomes from annual health checks, breast or cervical screening, ophthalmology results, nutritional risk monitoring and seizure‑specific details for people with epilepsy. In some cases, staff had not followed up outstanding health updates or ensured that advice was actioned. While many people experienced consistent day‑to‑day support from staff and external professionals, further and sustained improvement was needed to embed reliable recording, follow‑up and integrated oversight across all care pathways.

The provider made sure people received the information they needed in ways they understood, and information was available in formats that supported people’s communication needs.

People had communication passports, pictorial planners, flashcards and other augmented communication tools to help them express needs and understand choices. Staff told us they encouraged people to be involved in decisions by using visual aids, repetition and clear explanations. We saw staff interacting warmly and adapting how they communicated with people. One staff member provided gentle reassurance and a hug when someone appeared withdrawn, helping them engage positively with others. Relatives told us staff explained things clearly and kept them informed.

The provider made sure people and those important to them were listened to, involved in decisions, and able to share their views about their care and support.

Relatives told us they were routinely involved in discussions and felt staff listened to them. One relative said, “I am involved yes… we all have an input.” Another said staff “just ask me” whenever they needed information and that the person was now, “less isolated… it’s her family now” since moving into the home.

In several cases, families were consulted or updated on risks, changes in presentation or health needs, including diabetes management, community access, emotional wellbeing and activity planning.

Staff also described open communication and said families were welcomed and encouraged to raise concerns or feedback. The registered manager and senior staff told us they maintained an open‑door policy, and relatives confirmed they contacted the home regularly and felt respected and informed. One family member shared that although their relative sometimes complained, “[Staff] are always explaining the situation.” This kept them informed and reduced their stress.

The provider made sure that people could access the care, support and treatment they needed when they needed it.

People accessed a wide range of community activities, education sessions, healthy‑eating programmes and skill‑building opportunities. Many people told us they enjoyed going out with peers rather than alone, and staff supported them to attend clubs, college, shops, and events, with flexible staffing patterns designed to maximise participation. Relatives told us their family members had more opportunities since moving to the service.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

The provider needed to improve how they ensured people consistently experienced fair, positive and equitable outcomes, regardless of their needs, background, age or disability.

We saw examples of strong personalised work that led to improved outcomes for individuals. Social workers reported improvements for some people, including better emotional wellbeing, increased independence, reduced distress, improved continence, and increased community engagement. One professional wrote that a person who moved in with complex emotional, social and health needs had made “remarkable progress” and now felt “safe, cared for and loved” as a result of consistent support from the team.

Many people benefited from goal‑setting programmes, independent‑living skills, structured PBS interventions and community opportunities that improved confidence and wellbeing. Staff and relatives consistently spoke about people building friendships, enjoying activities and developing skills, including travel training, healthy eating, budgeting and college attendance.

However, outcomes were not equitable for everyone. Shortfalls in MCA practice and best‑interest processes meant some people did not always have decisions made appropriately or with the right involvement, which could negatively influence their experiences. While many people achieved positive outcomes, improvements were needed to ensure these improvements were sustained and embedded.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We saw people supported to explore goals around independence, community participation, learning, and daily living skills. Activity plans, enabling records and lifestyle planning showed people taking part in education, budgeting sessions, healthy‑eating programmes, volunteering, and skill‑building in enabling kitchens and laundry areas. One person told us they attended college 3 days a week and enjoyed completing homework, supported by staff. They told us, “This is a really good place. I didn't think I would be able to go to college, but I do.”

Relatives described being involved in discussions about people’s future wishes, including end‑of‑life considerations. Documents showed staff reviewed progress regularly, encouraged people to set long‑ and short‑term goals and worked with external professionals to ensure people’s future needs, such as mobility equipment, mental health support or communication tools, were anticipated and planned for. Staff and the registered manager described moving towards a model of smaller accommodation, increased independence and more personalised environments, with people contributing ideas to designs and arrangements.