Archived: St Mary's Lodge

Updated 12 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

St Mary’s Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Mary’s Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the CQC to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since its registration. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all of this information to plan our inspection.

During the inspection

We spoke with four people who used the service and two relatives about their experience of the care provided. We spoke with 10 members of staff including the registered manager, the regional manager, the area manager, a senior carer, housekeeper, administrator and care staff. We reviewed a range of records. This included three people’s care plans and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at further care records and spoke with two relatives about their experience of the service.

Updated 12 August 2022

About the service

St Mary’s Lodge provides care and accommodation for up to 26 older people who may be living with dementia. At the time of inspection there were 20 people living at the service in one purpose-built building.

People’s experience of using the service and what we found

People felt safe with staff. Risks to people’s health, safety and wellbeing had been assessed and staff understood how to help keep people safe. Processes in place ensured staff recruitment was appropriate with a range of pre-employment checks completed.

Staff were attentive to people’s needs and cared for them as individuals. People’s needs and choices were recorded following assessment. Care provided was personalised and considered their preferences and wishes.

The registered manager monitored staff deployment and ensured enough staff were on duty. People and relatives described care staff as knowledgeable and skilled and felt their privacy and dignity was respected.

People lived in an environment designed and fully equipped to support and maintain their independence.

People’s health needs were being met. The service worked closely with other health professionals and external agencies to support people with their health and wellbeing.

People were supported to have maximum choice and control in their lives and staff supported them in the least restrictive way possible and in their best interests.

People, relatives and staff spoke positively about the management of the service and their openness to feedback and the development of the service. They told us the registered manager was approachable, listened to them and maintained regular contact.

For more details, please see the full report, which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk.

Rating at last inspection

This service was registered with us on 18 March 2021 and this is the first inspection.

Why we inspected

The inspection was prompted in part due to concerns received about food and nutrition. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the effective section of this full report.

We looked at infection 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.

Follow Up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.