St Mary's Care 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 that 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.

The service was in continuing breach of legal regulation in relation to governance.

This service scored 59 (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 have a proactive and positive culture of safety based on openness and honesty. Further and sustained improvement was needed in the provider’s learning culture. While staff were open to feedback and some learning took place after incidents, systems for analysing patterns and embedding learning were not yet consistently effective. For example, charts used to monitor people’s periods of agitation and distress did not always contain information on how incidents had occurred and could be reduced in future.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

Further and sustained improvement was needed to develop and embed safe systems, pathways and transitions. Staff told us they were informed of changes through handovers, with 1 saying, “We have a daily handover which covers any changes. If anything was to change mid‑shift this would be communicated.” However, care records showed that important updates, such as outcomes of health appointments, were not always documented. Improvements were noted where leaders strengthened communication pathways, but systems for recording, reviewing and acting on risk‑related information remained inconsistent.

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.

People were generally protected from abuse, and staff understood their safeguarding responsibilities. Relatives told us they felt people were kept safe, with 1 saying “Oh yes, [named person is] safe enough.” Staff told us they would raise concerns immediately, with one stating “If I saw something concerning, I would report it right away… concerns are taken seriously and addressed promptly”.

The provider did not always work well with people to understand and manage risks. The service needed to strengthen how it involved people and those important to them in understanding and managing risks. Some relatives described positive involvement, with 1 telling us, “I am involved yes… we all have an input” when discussing care planning for their family member. However, others reported uncertainty about risk‑related decisions, such as a relative who said, “I have no idea” when asked about assessments. In one instance, a person was permitted to leave unsupervised at night despite being subject to a Deprivation of Liberty Safeguards (DoLS) authorisation. Staff had not completed a corresponding robust risk assessment for this decision and community leave was not explicitly stated as an agreed condition of that person’s DoLS authorisation. Following the inspection, the provider convened a multi-disciplinary meeting and completed a more robust risk assessment for similar future decisions. While staff encouraged independence and provided positive support, inconsistent consultation and recording meant people were not always fully supported to understand or contribute to decisions about risks.

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.

Governance systems had not always ensured the environment was safe. Unsafe areas were also accessible to people, for example a garden area was being used to store building material. We spoke with the registered manager and provider about this, and immediate action was taken to make the premises safe. However, these issues had not been identified or addressed by the provider’s governance systems.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff had not consistently received training for supporting people with learning disabilities and autistic people. Many staff described staffing levels positively, with one 1 saying, “Staffing levels are adequate… our management team always makes sure we are fully staffed.” Another told us, “I am more than happy with staffing levels and our manager always ensures we are fully staffed each shift.” However, training to give staff the knowledge and skills needed to support people with learning disabilities had not always been completed. At the time of our visit a majority of staff had not completed recommended training for supporting people with learning disabilities and autistic people. Following our visit additional training for staff was arranged. While leaders arranged further training and staff reported feeling supported through supervisions and regular communication, the inconsistent level of specialist knowledge meant staffing was not yet fully effective in meeting people’s needs safely.

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 service had effective approaches to infection prevention and control, with evidence of active learning and involvement of people using the service. Staff described training as helpful, with 1 saying, “They help me grow professionally and feel confident in my role, especially with up-to-date infection control and safety training.” Leaders also promoted good infection, prevention and control awareness amongst people using the service, developing an educational booklet and structured sessions in areas including hand hygiene.

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.

Medicines were managed safely. Well‑organised systems were in place, with records showing no gaps in administration and accurate stock balances during checks. Controlled drugs were stored securely, with clear records of their use in place. Staff worked effectively with people and healthcare professionals to reduce people’s medicines to the lowest effective dose in line with national guidance.