Archived: Saint Mary's Nursing Home

Updated 15 September 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This unannounced comprehensive inspection was undertaken on 14 August 2017. The inspection team consisted of one inspector, a specialist in dementia/mental health nursing care and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before our inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service: what the service does well and improvements they plan to make. We reviewed the previous inspection reports to help us plan what areas we were going to focus on during our inspection. We looked at other information we held about the service including notifications they had made to us about important events. We also reviewed all information sent to us from other stakeholders for example the local authority and members of the public.

We spoke with 18 people who used the service and two people’s relatives. We used the Short Observational Framework for Inspectors (SOFI). This is a specific way of observing care to help us understand the experiences of people. We also observed the care and support provided to people and the interaction between staff and people throughout our inspection.

We looked at records in relation to six people’s care. We spoke with the registered manager, the quality manager and seven members of staff, including catering, maintenance, nursing and care staff. We looked at records relating to the management of the service, training, three staff recruitment files and the systems for monitoring the quality of the service.

Updated 15 September 2017

Saint Mary’s Nursing Home provides accommodation, nursing and personal care for up to 40 older people, some people are living with dementia.

There were 28 people living in the service when we inspected on 14 August 2017. This was an unannounced inspection.

We carried out an unannounced comprehensive inspection of this service on 28 September 2015, we found breaches of regulation that affected the well-being of people using the service, this included safety, staffing and how the provider monitored the service that people received. The overall rating for the service was ‘Inadequate’. At a further comprehensive inspection of 27 June 2016 we found that there had been improvements made and the service was rated ‘Requires improvement’ overall. These improvements needed to be embedded in practice and sustained. The registered manager sent us reports on a monthly basis which kept us informed of the improvements they were making.

You can read the report from our last inspection, by selecting the 'all reports' link for Saint Mary’s Nursing Home on our website at www.cqc.org.uk.

At this comprehensive inspection of 14 August 2017 we found that the improvements previously made had been sustained and further improvements had been implemented.

There was a registered manager 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.

There were robust systems in place which supported the registered manager to monitor and assess the service provided to people. These systems allowed the provider and registered manager to effectively address shortfalls, take action to address them and put measures in place to minimise the risks of similar issues arising in the future.

Staff were provided with the training and support that they needed to meet people’s needs. There was a training plan in place to ensure that the staff’s knowledge was kept up to date. People had good relationships with the people using the service. People were treated with care and their independence, privacy and dignity was promoted and respected.

Systems were in place to minimise the risks to people and to keep them safe. This included risk assessments to identify how assessed risks were minimised and processes designed to keep people safe from abuse.

There was a system in place to assess how many staff were needed to meet people’s assessed and changing needs. This was kept under review to ensure that staffing numbers were increased if people required more care and support or if more people used the service. There were safe staff recruitment processes in place.

People’s care records had been reviewed and updated, they were more person centred and included the input from people and their representatives. Improvements had been made in the social activities provided for people to participate in to reduce the risks of isolation. There were plans in place to develop these further.

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.

Improvements had been made in the infection control and environment. Systems were in place to monitor the cleanliness of the service. There was an ongoing refurbishment plan in place.

People were provided with their prescribed medicines safely and when they needed them.

People’s dietary needs were assessed and actions were taken when there were concerns about people’s wellbeing relating to their nutrition and hydration. People were supported to see, when needed, health and social care professionals.

There was a complaints procedure in place and systems to respond and address to people’s comments, concerns and complaints.