We carried out a review of the data available to us about St Mary's Nursing Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Mary's Nursing Home, you can give feedback on this service.
St Mary's Nursing Home is a residential care home providing accommodation and nursing support to up to 56 people of all ages, some with a physical disability. The service provides care to people who require nursing support. At the time of our inspection there were 30 people using the service.
St Mary's Nursing Home accommodates people in one adapted building over two floors. The home had extensive gardens and outside spaces for people to enjoy.
People’s experience of using this service and what we found
People were supported by staff who understood what action to take if they had any concerns for their safety. Staff were provided with the guidance required so they could support people to manage their risks. There were enough staff to care for people and spend time chatting with them, so people did not feel isolated. The registered manager undertook checks before new staff worked at the home, so they could be assured new staff were suitable to work there. People were supported to have the medicines they needed by staff who had been trained to do this. The registered manager was improving medicine systems, so they could be assured staff consistently had the guidance they required to administer “when required” medicines. Systems were in place to reduce the likelihood of the spread of infections. The registered manager had worked with people and their visitors to ensure people continued to receive visits safely. Accidents and incidents were regularly reviewed so any lessons would be learnt.
People’s needs were assessed and informed through work with their relatives and other health and social care professionals. Relatives were complimentary about how staff used their skills and knowledge to support people. This included how staff monitored people’s health needs and advocated for them so they would enjoy the best health outcomes possible. Where staff had any concerns for people’s fluid or nutritional intake plans were developed to support them. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Since our previous inspection the registered manager and provider had made improvements to systems and procedures to provide a good quality service. Relatives and staff told us the culture at the home was open and focused on the needs of the people living at the home. This helped to ensure people had good outcomes. The registered manager and provider undertook checks on the quality and safety of the care provided.
Rating at last inspection
The last rating for this service was requires improvement (published June 2019) and there was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. After the last inspection we required them to send us an action plan showing how they were meeting the requirements of regulation 17. At this inspection we found the provider had completed actions on their action plan, there was no longer a breach of regulation 17.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 20 May 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.
We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of safe, effective and well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Mary's Nursing Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
St Mary’s is a care home, providing nursing, personal care and accommodation for up to 56 people. It provides care to older frail people, some of whom are living with dementia. The care home offers short respite nursing care stays and short stays for people discharged from local hospitals on a ‘Discharge to Assess’ basis. Care is provided over two floors. Each floor has communal lounges, dining areas and a kitchenette. At the time of our inspection visit 47 people lived at the home.
What life is like for people using this service:
People’s risks to safety and well-being were assessed, recorded and reviewed. Actions were taken to mitigate risks of harm and injury to people.
There were sufficient staff on during the day shift. A few staff felt the first-floor night time staffing was low and the registered manager told us they would review this.
People had their prescribed medicines available to them and were supported with these by nursing staff.
Staff received an induction, training and support from within the staff team and managers.
The home was clean and tidy, and staff understood how to prevent risks of cross infection.
People had their needs assessed before they moved into the home. However, people’s individual oral care needs were not always assessed.
Staff were suitably skilled to meet people’s day to day needs and protect people from the risks of abuse.
People had opportunities to engage in one to one activities, which reduced risks of social isolation.
People had access to healthcare when required.
Overall, people were offered enough food and drink to meet their dietary requirements. However, the lack of staff’s organisation at lunchtime meant two people did not receive their meals as intended.
People’s dignity was promoted by staff, who showed respect and valued people.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The provider's policies and systems in the service supported this practice.
Staff did not consistently complete important records related to people’s care and support. The registered manager and provider had not checked these records were completed by staff as required.
Overall, the provider’s quality assurance system identified where improvements were needed, but this was inconsistent and did not always ensure quality and safety.
We reported that the registered provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were:
Regulation 17 Regulated Activities Regulations 2014 – Good Governance
Rating at last inspection: At the last inspection the area of Well Led required some improvements and other areas were rated good. This gave the service an overall rating of Good. (The last report was published on 29 November 2016).
Why we inspected: This was a planned inspection based on the rating of the last inspection. The service is now rated as ‘Requires Improvement’ overall.
Enforcement: Action provider needs to take (refer to end of report).
Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk