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 that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 and communicated to staff to prevent reoccurrence.

Incidents and near misses were reviewed and analysed to identify any emerging patterns or themes. Analysis was used to inform improvements and support the delivery of safer care in the future.

Staff told us they were routinely updated on learning from incidents and significant events, including through digital communication platforms which ensured information was shared consistently between shifts.

Learning was disseminated across all teams to promote consistency of care. This ensured staff were aware of any changes to procedures or new ways of working introduced to enhance people’s safety and wellbeing.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People experienced safe and well‑coordinated pathways and transitions, supported by effective systems which ensured continuity of care. Robust processes were in place both prior to admission and during ongoing healthcare interventions from external health and social care professionals. Relatives told us they were informed when their family members required routine or urgent healthcare input, which helped maintain oversight of people’s safety and wellbeing.

Health and social care professionals reported a reliable flow of information when people accessed their services. One professional told us, “A member of the management team or one of the nurses is always available [to support].” This level of communication and accessibility ensured people received safe, continuous care across services, with transitions which were well planned and responsive to any changes in their needs.

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 told us they felt safe with the staff who supported them. One person said, “I do feel safe, there’s always someone nearby. I have no concerns; if I did, I’d raise it.” Relatives shared similar views and expressed confidence in the provider’s approach to keeping people safe.

Staff understood how to identify and escalate safeguarding concerns. Staff were confident senior staff would respond quickly and appropriately to protect people. One staff member told us, “Any type of abuse must not be tolerated. It is our job to notice it and to act. It must be reported. If you ignore it happening, you are as bad as the one doing it. I would report straight away. No hesitation. I do feel that they [registered manager] would take that very seriously. If they didn’t, I would report through other ways. The number is in the staff room. I would call that.”

Senior leaders acted openly and transparently with relatives and external safeguarding agencies when safeguarding measures needed to be put in place to protect people.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. The provider had identified where a deprivation of liberty needed to be authorised and had submitted the required applications to the supervisory body.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them.

People and relatives were positive about how risks were managed. A person told us staff supported them to maintain their safety and said, “There aren’t any risks at all. I haven’t had any falls, because if I go to the toilet I have to have a carer with me.” Another person told us, “I have a shower every day, they always stay with me in case [of a fall].”

Staff showed a good understanding of managing risks linked to people’s individual needs. For example, they explained how addressing underlying causes, such as treating infections, formed part of their approach to reducing falls.

People’s care records outlined their risk histories. People’s risks were clearly identified, understood and managed safely. For example, where people had risks associated with their health diagnosis , detailed risk assessments and care plans had been put in place to manage these. Robust risk‑management plans were also in place to minimise risks associated with people’s mobility, experiencing anxiety and to reduce the likelihood of people contracting infections.

However, while most risks were managed well, we noted 1 instance on the first day of the inspection where a person’s pressure relieving mattress was not providing the full level of protection intended because it had not been set properly. Although staff had completed checks, the setting was still not accurate on the second day of the inspection. The registered manager responded constructively, acknowledged the issue, and confirmed they would take immediate steps to put this right.

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.

Although staff were able to clearly explain what they would do in the event of a fire, some of the essential supporting information and records needed by staff and emergency services were either missing or not fully up to date. This had been rectified by the second day of the inspection, but staff will need ongoing reminders about where personal emergency evacuation plans were stored to ensure safe practice and consistent risk reduction.

We also asked the registered manager to review window restrictors to ensure they were reliably tamper‑proof. In addition, on the first day of the inspection we found some wardrobes were not secured to the walls. The registered manager took immediate action to address this.

However, people told us they liked their rooms, which were personalised and reflected what was important to them. Staff supported people’s safety by carrying out regular environmental checks, including routine monitoring of utilities such as water, gas and electricity. The provider was also progressing a comprehensive refurbishment of the home to ensure the premises continued to meet people’s needs.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were positive about the availability and skills of staff to support them. A person told us, ‘I’ve got no apprehensions about staff, they seem quite well trained. I’ve no cause of concerns about staffing levels here.” Relatives told us there were sufficient staff to meet their family member’s needs. A relative said, “I think staffing levels are fine. [Person’s name] says there are less at weekends, but it doesn’t cause them a problem.”

Staff told us there was enough time to provide care to people. A reduction in the number of agency staff as new staff were recruited helped ensure people were cared for by staff who knew them well.

Systems were in place to ensure staff were recruited safely. This included checking their eligibility to work in the UK, obtaining references and Disclosure and Barring Service (DBS) checks. The DBS checks help employers make safer recruitment decisions and prevents unsuitable people from working with vulnerable people.

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.

People told us the home was kept clean and said domestic staff supported them well. A person told us, “I have a cleaner in every day, she keeps my room very clean, she’s very nice.” Another person said, “[Staff member’s name] is my cleaner, they do a good job.” Most relatives were also positive about the cleanliness of the environment, although 1 relative noted cleaning needs were not always identified as promptly at weekends.

Throughout the inspection, communal areas and people’s bedrooms were clean, tidy and maintained to a safe, hygienic standard.

Staff confirmed they had access to the PPE and equipment they needed to support people safely and people confirmed staff used this appropriately. Visiting professionals advised us PPE was readily available, should they require this. Staff had received training to help prevent the risk of infection spreading. Guidance posters were displayed throughout the home to support staff in following effective infection control measures.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Although there was no evidence anyone had been harmed, some aspects of medicines management required further improvement. The provider had already identified these issues before the inspection and was introducing an electronic medicine recording system to ensure records accurately reflected medicines in stock and those administered.

Further improvements were needed to ensure people’s prescribed creams were consistently dated and applied as directed, supported by clear guidance for staff on how and where to apply them. Risks associated with the use of emollient creams had also not been fully considered, and some people’s insulin pens were not labelled. The registered manager addressed these areas by the second day of the inspection.

However, people were positive about how their medicines were managed, and we found medicines were given at the correct times. One person told us, “If I’m in pain, [staff] give me paracetamol.”

Staff were only allowed to administer medicines once they had completed training and had their competency checked. Safe arrangements were in place to manage ‘as required’ medicines, and covert administration of people’s medicines was supported by pharmacist guidance. Rotation charts were used to ensure transdermal patches were applied safely.

Staff had developed detailed, evidence‑based care plans for people with high‑risk conditions such as diabetes, epilepsy or those receiving anticoagulation therapy. These included clear guidance on side effects and what to do in an emergency. People’s medicines were stored and disposed of safely.