CQC report explained · a nursing home
What the CQC found at Mary House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found unsafe medicines and hydration arrangements, although care, activities and health support had improved.
This was an unannounced follow-up inspection over 18, 19 and 25 May 2023. Two inspectors observed care, spoke with staff, relatives and professionals, and checked care plans, medicines, recruitment records, audits and other records.
The home was rated Requires Improvement overall. Safe and Well-led were Requires Improvement. Effective and Responsive improved to Good. Inspectors found kind, person-centred support, more activities and good access to health professionals.
There were continuing breaches of Regulation 12, about safe care and treatment, and Regulation 17, about good governance. Medicines were not always managed safely, some people were at risk of dehydration, and checks had failed to identify important problems.
Kind, person-centred support
Inspectors saw staff respond warmly to people and support them according to their preferences. People's privacy and dignity were maintained.
“We observed staff supporting people with kindness and compassion.” from the report
More activities and outings
The home had increased the range of activities and outings. People took part in activities such as flower arranging, karaoke, carriage driving and trips to places of interest.
“The number and range of activities had increased since our last inspection, and people were going out more to places of interest.” from the report
Improved mental capacity practice
The home was working within the principles of the Mental Capacity Act. Capacity assessments and best-interests decisions were recorded when needed.
“We found the service was working within the principles of the MCA and where appropriate, authorisations were in place to deprive people of their liberties.” from the report
Access to health professionals
People were supported to access GPs and specialist services. The GP visited weekly and referrals were made to services such as dentistry, optometry, physiotherapy and speech and language therapy.
“People's GP visited the home weekly to check on their welfare.” from the report
Improved staff morale
Staff told inspectors they felt supported and morale had improved. Regular agency staff knew people well, although vacancies remained high.
“There was a very noticeable improvement in the morale of staff at this inspection.” from the report
Medicines were not consistently safe
seriousMedicines were prepared in advance and were not always signed for by the staff member who gave them. Around half of the care staff had not been assessed as competent to give medicines, and some as-required medicine guidance was not person-specific.
“The provider had not ensured the safe and proper management of medicines.” from the report
Risk of dehydration
seriousSome people had gaps of 12 to 17 hours between drinks. The home had not yet developed a person-centred plan for people who regularly declined drinks or could not safely drink while in bed.
“This meant that there were regular gaps of 12 -17 hours between drinks.” from the report
Weak quality checks
seriousThe home's audits had failed to identify problems with medicines, recruitment records, epilepsy guidance, fire drill records, incident reports and enteral feeding supplies.
“The provider did not have effective systems to assess, monitor and improve the quality and safety of the services provided.” from the report
Communication could be difficult
needs fixingSome relatives and professionals said it was difficult to contact the home and that messages were not always answered promptly. New phones had been ordered to help with evening and weekend calls.
“Relatives of 3 people said they had difficulty contacting the home by phone, 2 said they had left messages, and no one got back to them.” from the report
High staff vacancies
needs fixingThe home still had very high staff vacancies and relied heavily on regular agency staff, particularly for nursing cover at night. A health professional said training had been cancelled because of staff shortages.
“Although the home continued to have very high staff vacancies, staff worked overtime and they continued to use regular agency staff.” from the report
- 01What has changed in the medicines system since the inspection, and is every staff member who gives medicines now assessed as competent?
- 02How do you make sure as-required medicines are given correctly and that their effect is recorded?
- 03What individual plans are now in place to make sure people receive enough fluids, especially those who regularly decline drinks or cannot drink safely in bed?
- 04How are you checking that problems with records, medicines, incidents and staff recruitment are identified and corrected promptly?
- 05How can relatives contact the home in the evenings and at weekends, and how quickly are messages answered?
This was an unannounced follow-up inspection that focused on Safe and Well-led; the Effective and Responsive ratings changed to Good, while the report says ratings for key questions not inspected carried over from the previous inspection. This explanation was written from the published report of 12 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Mary House was rated Requires Improvement; inspectors found kind staff but unsafe medicines, staffing shortages and care that did not always respect people's needs or choices.
This was an unannounced focused inspection. Inspectors visited on 25 and 26 October, 30 October and 1 November 2022. They observed care, spoke with relatives, staff and professionals, and reviewed care plans, daily records, medicines records and quality checks.
The home supported 14 people with complex learning disabilities, autism and physical disabilities. Inspectors found staff generally knew people well and were kind and caring. However, medicines were not always managed safely. There were not always enough staff, and people did not always receive their planned support, activities, drinks or time outside.
People were not always offered choices or supported in the least restrictive way. Communication aids and preferred communication methods were not used consistently. Records did not always show what care people had received, and audits had failed to identify important problems.
The ratings for Safe, Effective, Responsive and Well-led all changed from Good at the previous inspection to Requires Improvement. Caring was not assessed during this focused inspection. The overall rating was Requires Improvement.
Kind staff
Inspectors saw most staff treating people with kindness and respect. Staff spoke positively about the people they supported.
“People were supported by kind and caring staff. Staff spoke positively about people.” from the report
Knowledge of health risks
Staff understood people's choking risks, epilepsy protocols and positive behaviour support plans. They knew how to support people safely in these areas.
“Staff were able to tell us how they supported people safely with their food and drink and how they would respond to incidents of choking.” from the report
Specialist care training
Staff had training linked to people's complex needs, including catheter care, oxygen therapy, suctioning and intensive interaction.
“Staff received training that was specific to people's care and support needs.” from the report
Personalised bedrooms and facilities
Bedrooms were personalised with items important to each person. The home also had sensory, IT and hydrotherapy facilities.
“Each person's bedroom was different and unique to them.” from the report
Some meaningful activities
People took part in arts and crafts and decorating for Halloween. Records also showed that people enjoyed a visit from animals.
“People's records showed that they had recently received a visit from a company that brought animals into the home.” from the report
Unsafe medicines processes
seriousCare staff gave medicines without having been trained or competency checked to administer them. Records and guidance for creams and as-needed medicines were also incomplete or unclear.
“Medicines were not always managed safely.” from the report
Not enough staff
seriousStaff shortages affected one-to-one support, drinks, personal care, activities and trips outside. Some people did not receive the level of support recorded in their plans.
“There were not always enough staff to provide people with person centred care.” from the report
Consent and least restrictive care
seriousPeople were not always offered choices, and staff sometimes moved people or gave medicines in food without showing that the necessary decisions had been properly assessed.
“People were at risk of receiving their medicines without their knowledge or the authorisation to hide their medicines.” from the report
Care not consistently personalised
seriousStaff did not always follow recorded preferences, use preferred communication methods or provide suitable activities. Some people missed regular outings and hydrotherapy.
“People's support was not always provided in line with the person's recorded preferences.” from the report
Inaccurate or incomplete records
seriousRecords did not always show whether people had received enough food, fluids or planned support. Audits had not found several of the problems identified by inspectors.
“The provider's processes for quality assurance and audit were not robustly applied.” from the report
Relatives' concerns not always recorded
needs fixingThere was a complaints process, but informal concerns from relatives were not recorded in a measurable way. Some relatives did not feel comfortable raising concerns with management.
“Concerns raised informally by people's relatives had not been recorded in a measurable way.” from the report
- 01How many permanent and agency staff are currently working, and how do you make sure there are enough staff for one-to-one support, drinks, activities and trips out?
- 02Who is authorised and trained to administer medicines, and how are medicine records and topical creams checked now?
- 03How do you record and review people's capacity and best-interest decisions, including medicines given with food and restrictions on movement?
- 04How do you make sure staff use each person's communication aids, preferred communication methods and recorded personal care preferences?
- 05What action has been completed in response to the warning notices, and what evidence can you show that records and quality audits have improved?
This was an unannounced focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected, and the report says the overall rating used the previous ratings for any questions not inspected. This explanation was written from the published report of 17 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Mary House
7 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- July 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2018Goodstayed GoodSafe: GoodEffective: GoodResponsive: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2015Requires improvementup from InadequateSafe: Requires improvement
- April 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- October 2014Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- December 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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