CQC report explained · a nursing home
What the CQC found at St Mary's Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, suitable risk management, safe medicines systems and effective infection control, but some records and medicines guidance needed updating.
- Effective?
- Good
- This question was not rated during this inspection. The report says staff received regular training and worked with healthcare professionals to meet people's needs.
- Caring?
- Good
- This question was not rated during this inspection. Inspectors observed staff treating people with respect, compassion and dignity.
- Responsive?
- Good
- This question was not rated during this inspection. The report describes personalised care, activities and support for people's cultural and end-of-life needs.
- Well-led?
- Good
- The home had a clear leadership structure, regular audits and staff support. Feedback was gathered, but overall analysis of surveys had not been completed.
What inspectors found, August 2022
St Mary's Care Home was rated Good; inspectors found safe, kind care, but some records and medicines guidance needed updating.
This was an unannounced inspection on 29 June 2022. Inspectors reviewed care, risk and medicines records, recruitment files and management information. They spoke with six people, five family members, staff and healthcare professionals.
The home was rated Good overall, with Good ratings for Safe and Well-led. Inspectors found enough staff, safe medicines management, suitable infection control and good risk management. People were described as safe, valued and treated with kindness.
There were some areas to improve. Parts of people's records about capacity, mobility and continence were incomplete or lacked detail. Some guidance for medicines given when needed was out of date. The manager took immediate action, and CQC said it would check progress at the next inspection.
The other three areas, Effective, Caring and Responsive, were not rated in this inspection. The previous overall rating was also Good, published on 24 February 2021.
Enough staff
Inspectors saw enough staff to meet people's needs promptly. Staff checked on people regularly and offered drinks frequently.
“We observed staffing levels throughout the day and saw that there was enough staff to meet people's care needs in a timely manner.” from the report
Safe medicines
Medicines were given as prescribed by trained staff. Records and stock balances matched, and medicines were stored securely.
“The Medication Administration Record (MAR) charts were completed accurately and stocks tallied with the balances recorded.” from the report
Kind and respectful care
Staff spent time with people and supported their preferences. Inspectors saw staff communicate warmly and respect people's privacy and dignity.
“We observed staff communicating with people in a warm and friendly manner. Staff treated residents with respect, compassion and dignity.” from the report
Strong working relationships
Healthcare professionals said the home was easy to work with and responded quickly to guidance and recommendations.
“This allows issues to be resolved quickly and allows the adoption of new ways of working very straight forward.” from the report
Some care records lacked detail
needs fixingSome records about people's capacity, mobility and continence were incomplete or needed more detail. The home took immediate action, but CQC planned to check this again.
“Although staff were well aware of people's care needs and people received the support as necessary, we found that some records required more detail and/or full completion to ensure continuity of care delivery.” from the report
Some medicines guidance was out of date
needs fixingGuidance for some medicines given when needed was not current. Staff said they would review it immediately.
“However, some guidance was out of date which the staff team told us they would review immediately.” from the report
Feedback analysis was incomplete
minorThe home collected feedback and acted on individual comments, but had not completed an overall analysis to identify wider improvements.
“However, the overall analysis was not completed which the registered manager told us they would address going forward making sure the feedback was used to drive improvements to the quality and safety of the services.” from the report
- 01What changes have you made to care records about capacity, mobility and continence since the inspection?
- 02How do you check that guidance for medicines given when needed is current?
- 03How do you now analyse feedback from people, relatives and staff as a whole?
- 04How will you show families that the improvements identified by inspectors have been completed?
- 05Which aspects of Effective, Caring and Responsive care can you explain to us, as these were not rated in this inspection?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other three question areas were not rated in this inspection. This explanation was written from the published report of 20 August 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.
What inspectors found, February 2021
St Mary's Care Home was inspected but not rated; inspectors were assured that infection control measures were keeping people safe.
This was an announced inspection on 27 January 2021. It was carried out because the home had been identified as a designated setting for people discharged from hospital with a positive COVID-19 status.
Inspectors looked at infection prevention and control. They found controls for visitors, hand hygiene, face coverings, personal protective equipment, testing, isolation, cleaning and social contact. They were assured that the home was managing infection risks safely.
The home was not given an overall quality rating, and the Safe question was recorded as inspected but not rated. The other four questions were not assessed in this report.
Visitor safety
Visitors were screened for COVID-19 symptoms and had to follow hand hygiene and face-covering arrangements.
“All visitors were screened for symptoms of COVID-19 before being allowed to enter the home.” from the report
Keeping families connected
The home offered video calls, garden visits and a specially adapted pod so people could keep in touch with relatives safely.
“Alternative forms of maintaining social contact were used for friends and relatives” from the report
Protective equipment and testing
Staff had access to PPE and had received infection control training. People and staff were included in COVID-19 testing arrangements.
“Staff have received training from an Infection Prevention and Control (IPC) specialist at Clinical Commissioning Group.” from the report
Cleaning
Cleaning schedules covered high-touch areas, and records showed that the schedules were being followed.
“Records/checks of cleaning showed compliance with the cleaning schedule.” from the report
Access to the temporary discharge unit
needs fixingInspectors identified an uneven pathway that could be a trip hazard, especially for people with limited mobility. They also asked for barrier screens and clearer signs to reduce crossover between the temporary unit and the rest of the home.
“We asked the provider to consider the risk this could pose to people as the pathway leading to the TADD was uneven in parts and a trip hazard” from the report
- 01What infection prevention arrangements are currently in place for visitors, including screening, face coverings and hand hygiene?
- 02How are people who are admitted to the home tested and supported during any isolation period?
- 03Has the pathway to the temporary discharge unit been levelled, and are barrier screens and clearer signs now in place?
- 04How do you prevent staff and residents from crossing between the temporary discharge unit and the rest of the home?
- 05Can you show us the home's current ratings for Effective, Caring, Responsive and Well-led, as these were not assessed in this report?
This was an announced inspection focused on infection prevention and control because the home was being considered as a designated setting; the other four quality questions were not assessed. This explanation was written from the published report of 24 February 2021 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 St Mary's Care Home
8 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- August 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2021Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2018Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2016Goodstayed GoodSafe: Good
- November 2015Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementstayed Requires improvementSafe: Requires improvement
- October 2014Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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