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 avoidable harm. Inspectors found suitable risk assessments, safe recruitment, enough staff, safe medicines procedures and good infection control.
- Effective?
- Good
- Staff had appropriate training and support. People received enough food and drink and were helped to access health services, although some mental capacity decisions were not clearly recorded or reviewed.
- Caring?
- Good
- Staff were kind, respectful and knew people's needs and preferences. Inspectors did see two occasions when people's dignity was not fully protected while they were being moved.
- Responsive?
- Good
- Care plans were detailed and personalised, and staff supported people's interests and end of life wishes. Some people felt lonely in their rooms in the evening, and one person's specific end of life anxieties were not included in their care plan.
- Well-led?
- Good
- The home had an open and caring culture. Managers used audits, feedback and incident reviews to monitor the service and make improvements.
What inspectors found, July 2019
St Mary's Care Home was rated Good overall; inspectors found safe, kind and well-organised care, with some records and activities needing attention.
This was an unannounced inspection on 24 and 25 June 2019. The inspectors spoke with people living there, relatives, staff and a healthcare professional. They also checked care records, staff files, audits and meeting records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines systems, detailed care plans, good food and support from health professionals. People were treated kindly and were involved in decisions about their care.
There were some areas to improve. Two people were not sufficiently covered when being moved around the home. Some decisions made for people who lacked capacity were not clearly recorded or reviewed. Some people felt lonely in the evenings, and one person's end of life concerns were not recorded clearly in their care plan.
Safe staffing and care
There were enough staff to meet people's assessed needs. Staff were trained to recognise concerns, manage risks and handle medicines safely.
“Staff worked well together to ensure people were safe and well cared for.” from the report
Detailed personal care
Care plans gave staff clear guidance about people's needs, preferences and risks. People's care was reviewed and adapted when needed.
“People's care plans were detailed and provided staff guidance on how to meet each person's needs.” from the report
Kind and respectful staff
Inspectors saw friendly interactions and found that staff knew people well. Staff supported independence and involved people in everyday decisions.
“Staff supported people in a sensitive and friendly way.” from the report
Good food and health support
Staff worked hard to meet people's food preferences and supported people to eat and drink enough. They also worked with outside health professionals.
“Staff supported people to have enough to eat and drink and maintain a healthy weight.” from the report
Dignity during moving
needs fixingInspectors saw two occasions when people were not sufficiently covered while being moved around the home. The manager said this would be addressed.
“Overall, people were treated with respect, however we saw two occasions when people's dignity was not protected, and they were not sufficiently covered when moving around the home.” from the report
Mental capacity records
needs fixingSome decisions made with relatives, professionals or advocates were not clearly recorded. Records were also not always reviewed when someone regained capacity to make a decision.
“However, these were not always clearly recorded or reviewed when people regained the mental capacity to make a specific decision.” from the report
Evening loneliness
minorSome people felt isolated in their rooms because there was less activity and less time to chat in the evening. The manager had identified this as an area for development.
“Nothing much is happening after 6pm and [my family member] is not one to go to bed early.” from the report
One end of life plan
needs fixingMost people's end of life plans were clear, but one person's specific anxieties were not included in their care plan. The manager said this would be followed up.
“However, one person had raised specific anxieties, but their care plan did not guide staff in how to address these.” from the report
- 01What action have you taken to make sure people are properly covered and their dignity protected when they are moved?
- 02How do you record best interest decisions, and how do you review them when a person's mental capacity changes?
- 03What activities or social contact are available after 6pm for people who do not want to go to bed early?
- 04How do you make sure each person's end of life anxieties and wishes are recorded clearly in their care plan?
- 05How will the refurbishment affect residents, staffing, rooms and daily routines while part of the building is closed?
This was an unannounced planned inspection covering all five CQC questions and both the premises and care; all ratings remained Good, as at the previous inspection published in 2016. This explanation was written from the published report of 23 July 2019 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, October 2016
Rated Good; inspectors found safe, kind and responsive care, with some remaining concerns about staffing waits, records and management arrangements.
This was an unannounced inspection on 29 July 2016. Inspectors spoke with people living at the home, relatives and staff. They reviewed care records, medicines, complaints, staff checks and training, and watched care in shared areas.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff planned to meet people's needs safely, medicines were managed safely, and staff had suitable training and support.
People were treated kindly and with respect. Their care plans reflected their needs and choices, activities were available, and complaints were investigated. Improvements had been made since the July 2015 inspection, including the lounge, call bell monitoring and care records.
There was no registered manager, although a new manager had started the registration process. Inspectors also identified some areas to keep watching, including occasional waits for staff, incomplete detail in one diabetes care plan, mixed views about food and some concerns about teamwork between nurses and care staff.
Safe care and medicines
Inspectors found clear risk assessments, safeguarding arrangements, safe recruitment and safe medicines processes. Medicines records reviewed were complete, with no unexplained gaps.
“The medicine administration records (MAR) we looked at had been completed fully, with no unexplained gaps.” from the report
Kind and respectful staff
People were treated in a friendly and respectful way. Staff supported privacy, dignity, choice and independence.
“Staff were kind and caring towards people they supported.” from the report
Improved care planning
Care plans had improved since the previous inspection and reflected people's needs, preferences and choices. They were reviewed when people's needs changed.
“We found improvements had been made during this inspection and staff had had enough time to embed the changes the provider had made to the care plan records.” from the report
Activities and community access
The home provided a range of activities, including exercises, arts and crafts, music and trips into the local community. The garden was accessible and well maintained.
“We saw evidence that a variety of activities had been planned and provided to support people to socialise, and pursue their hobbies and interests.” from the report
Action after feedback
The provider collected views from people, relatives and staff and used an action plan to address suggestions and improvements.
“This showed that the provider acted on people's comments in order to improve the service.” from the report
Occasional waits for help
needs fixingSome people and relatives said they sometimes waited for staff, particularly when the home was busy. Inspectors found staffing levels planned as sufficient, but this is worth checking for someone who needs quick assistance.
“Sometimes the wait can be five or ten minutes.” from the report
Missing detail in a diabetes care plan
needs fixingOne care plan did not state which blood sugar readings should concern staff. The manager agreed this information was essential and said it would be added.
“The information on a care plan of a person living with diabetes who required staff to check their blood sugar levels if they felt the person was unwell did not tell staff the range in which the blood sugar levels would be of concern.” from the report
No registered manager
minorThere was no registered manager when inspectors visited. A new manager had started the registration process, but some people were unclear about who managed the home.
“There was a no registered manager in post, but a new manager had started the process to register with the Care Quality Commission.” from the report
Mixed views about food
minorMost people and relatives were positive about the food, but some said it could be hit and miss or too fatty. Inspectors observed nutritious food and suitable choices.
“Breakfast is not bad, but lunch is hit and miss. There is not much substance to the food.” from the report
Teamwork between nurses and care staff
needs fixingSome care staff said improvements were still needed in how nurses worked with them. This differed from the views of other staff and from what inspectors observed that day.
“We still have a problem where some nurses do not work well with us as part of a team.” from the report
- 01How quickly are call bells answered during busy periods, and how do you check for delays?
- 02Has the new manager completed the process to register with the Care Quality Commission?
- 03How will you make sure diabetes care plans include the blood sugar levels that require action?
- 04How do you monitor and respond to people's views about the quality and variety of food?
- 05What has been done to improve teamwork between nurses and care staff?
This was an unannounced inspection of all five key questions and included checks of care records, medicines, staffing, complaints, training, quality monitoring and observed care. This explanation was written from the published report of 15 October 2016 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
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- October 2010
Registered with the Care Quality Commission on 1 October 2010.
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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