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Inspection Summary

Overall summary & rating


Updated 20 March 2018

We inspected St Mary’s Hospital on 4, 5 and 6 December 2017 and 1 and 2 February 2018. The inspection was announced because we wanted to ensure people, their relatives and staff were available to support the process.

At the last inspection in July 2016 we found the provider had breached two regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to medicines management and overall oversight of the service including appropriate reporting of incidents. The service was rated overall Requires Improvement.

An action plan was submitted to us by the provider outlining how they would improve. We saw improvements had been made in all areas at this inspection and the provider was no longer in breach of any regulations. The service is now rated overall Good.

The service provides care and support to people living in 16 ‘supported living’ settings, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support. 91 people were supported at the time of the inspection.

The care service has been developed and designed in line with the values that underpin the ‘Registering the Right Support’ and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and/ or autism using the service can live as ordinary life as any citizen.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received an extremely person centred service. Staff had excellent knowledge around how people communicated and they used this to empower people to make their own decisions and direct their own care. The use of positive behavioural support had meant people were less anxious and confident enough to access their community and live as ordinary a life as possible. Care plans reflected the person centred detail staff needed to know to support people how they preferred.

Staff training in specialist areas such as postural management meant people experienced less discomfort or pain due to their physical disabilities and improved mobility and independence. Staff felt supported by their managers and enjoyed the range of training on offer to develop their skills. Their improved knowledge helped them deliver effective support for people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, the policies and systems in the service supported this practice. Staff understood how to recognise abuse and report issues of concern to protect people.

People and their families were able to describe the positive outcomes achieved because they received such high quality person centred support. Staff treated people with respect and dignity at all times. Staff looked to problem solve and worked to support people to achieve their aspirations. We saw examples of people improving their health, accessing their dream holiday, starting a new hobby and using technology to control their own environment.

The leadership and culture of the service was positive. Managers empowered their staff to have ideas and be part of developing the service. There was energy behind continuous improvement and we saw people were innovatively involved in developing the service.

New quality assurance processes were in place to help the provider ensure quality was consistent. Systems were in place to ensure staff were recruited safely and that the health and safety aspect of delivering support

Inspection areas



Updated 20 March 2018

The service was safe.

Medicines, recruitment of staff and health and safety were well managed.

The use of positive behavioural support (PBS) had reduced people�s anxiety and distress to enable them to be more independent and have more positive feelings of wellbeing.

Where accidents and incidents occurred, the provider had reviewed information to understand patterns and trends and learn lessons to prevent the likelihood of a reoccurrence.



Updated 20 March 2018

The service was effective.

Staff used best practice knowledge to support people to receive effective support around their health and social needs.

Staff were well trained and supported by the provider.

Staff had very good links with professionals to ensure people received appropriate healthcare and equipment to improve their independence and prevent discomfort.



Updated 20 March 2018

The service was extremely caring.

Staff had excellent and detailed knowledge of how people communicated and they used this to offer choice and empower people to direct their own support.

A strong person centred culture ensured people received care how they preferred it. This included exceptionally innovative ways to support people to be actively involved.

Relatives and advocates were positively used and welcomed to ensure the care and support delivered was respectful and dignified for people.



Updated 20 March 2018

The service was responsive.

People received support to access a wide range of activities both in their own home and in the community.

A model of active support was used to make day to day activities meaningful. The provider was working to ensure appropriate staffing meant each person could receive such responsive support.

Where people required end of life care this was delivered with compassion and ensured people were comfortable and pain free.

People and their relatives knew how to raise concerns.



Updated 20 March 2018

The service was well led.

Innovative ways were used to support people with learning disabilities and/ or autism to give their views about the service they received.

A new quality assurance system was being implemented to help the provider understand whether consistent high quality care was being delivered for each person.

The registered manager understood their responsibilities and fostered a positive culture in the service. Staff told us morale was high and they were appreciated.

Other CQC inspections of services

Community & mental health inspection reports for St Mary's Hospital can be found at Leeds and York Partnership NHS Foundation Trust.