CQC report explained · a nursing home
What the CQC found at St Mary's Continuing Care
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2019
St Mary's Continuing Care was rated Good overall; inspectors found kind, person-centred care, with some medicines and confidentiality procedures needing improvement.
This was an unannounced planned inspection. Inspectors spoke with people living at the home, relatives, staff and other professionals. They observed care and reviewed care records, medicine records, recruitment files and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, treated with kindness and involved in decisions. Care was personalised, activities were varied, and staffing levels were sufficient.
There were some shortfalls. Medication audits were not always completed as often as the home's policy required, and some medicines were not stored in locked cabinets. Some confidential information was not safely stored. One unit needed extra attention, and some policies needed review.
The overall Good rating was unchanged from the previous inspection, published on 7 December 2016. The report says the home remained Good, but the provider was asked to review medication procedures and submitted an action plan.
Kind and respectful care
Inspectors saw staff treating people with dignity and kindness. People and relatives gave positive feedback about the care.
“We observed kind, considerate and compassionate interactions between staff and people receiving support.” from the report
Personalised support
Care records included people's preferences, wishes and communication needs. Staff knew the people they supported and encouraged choice and independence.
“People received high quality, person-centred care.” from the report
Safe staffing and recruitment
Staffing levels were reviewed against people's needs. Recruitment checks, including DBS checks, were completed.
“Staff were effectively deployed across the home and people received support from sufficient numbers of nursing and care staff.” from the report
Activities and social contact
The home offered varied activities, including baking, crafts, trips and music therapy. Inspectors said these helped reduce social isolation and support wellbeing.
“A variety of different activities were scheduled such as baking and craft events, barge trips, Shetland pony visits.” from the report
Quality monitoring
The manager used audits, incident reviews and meetings to monitor care and identify improvements. Feedback from people and relatives was acted on.
“A variety of different quality assurance tools, audits and checks were in place.” from the report
Medication procedures were not always followed
needs fixingMedication audits did not always happen as often as the provider's policy required. Inspectors also found some medicines in locked rooms but not in locked cabinets.
“We did identify that the providers medication administration policy was not always complied with.” from the report
Medicine storage
needs fixingSome medicines were not stored in locked cabinets, although the medication rooms themselves were locked. The provider was recommended to review its procedures.
“Medicines were found in locked medication rooms but were not always stored in locked cabinets.” from the report
Confidential information
needs fixingSome confidential information was not safely stored or protected under data protection requirements. The manager acted immediately after inspectors raised this.
“Not all confidential information was safely stored away or protected in line with General Data Protection Regulations (GDPR).” from the report
One unit needed attention
minorInspectors found that one unit needed some extra care and attention. The provider responded to this feedback.
“One unit required some extra care and attention.” from the report
Policies needed review
minorSome policies needed to be reviewed and renewed. The manager was also reminded to ensure staff followed the policies.
“Some policies needed to be reviewed and renewed and the registered manager needed to ensure that policies were being complied with.” from the report
- 01How often are medication audits now completed, and how do you check that medicines are stored in locked cabinets?
- 02What changes were made after the inspection to ensure the medication administration policy is followed?
- 03How are confidential records and other personal information kept secure now?
- 04What work was completed in the unit that inspectors said needed extra care and attention?
- 05Which policies have been reviewed or renewed since the inspection, and how is staff compliance checked?
This was an unannounced planned inspection that looked at the premises and care provided and assessed all five CQC questions. This explanation was written from the published report of 6 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, December 2016
St Mary's Continuing Care was rated Good; inspectors found safe, caring support, with some care records and staffing checks still being improved.
The inspection was unannounced and took place on 12 and 13 October 2016. One inspector spoke with people living in the home, relatives and staff. They reviewed care records, staff files, medicines, complaints, audits and the building.
The home was rated Good in all five areas: safe, effective, caring, responsive and well-led. Inspectors found kind and respectful staff, enough staff on duty, safe medicines management and suitable training. People's care plans reflected their needs, choices, hobbies and interests.
The registered manager had systems to monitor quality, accidents, medicines, staffing and care planning. Some improvements were still under way. The staffing tool did not always reflect people's needs, care plans were being updated, and resident and relative meetings were not well attended.
Enough suitable staff
Inspectors found robust recruitment checks and staffing levels that supported people safely across the four units.
“There were robust recruitment processes in place. There were enough skilled and experienced staff to support people safely.” from the report
Kind and respectful care
People and relatives praised the staff. Inspectors observed warm communication, respect for privacy and support for individual choices.
“People were supported by kind and caring staff.” from the report
Individual care planning
Care plans included people's histories, preferences, communication needs, hobbies and choices. Staff reviewed care when people's needs changed.
“People's needs had been assessed and appropriate care plans were in place to meet individual needs.” from the report
Quality monitoring
The home carried out regular checks covering areas such as medicines, accidents, staffing, safeguarding and care planning. These checks were used to make improvements.
“Quality monitoring audits were completed regularly and these had been used effectively to drive continuous improvement.” from the report
Staffing tool needed improvement
needs fixingThe tool used to assess staffing levels did not always reflect the needs of people living in the home. The manager was researching a more suitable tool, although inspectors found staffing levels were sufficient at the time.
“However, discussions with her identified that this tool did not always reflect the needs of the people living in the home.” from the report
Care plans were being updated
needs fixingThe manager was updating care plans to make information about health conditions, risk monitoring and prevention more consistent.
“The registered manager told us that all care plans were in the process of being updated to ensure that they held consistent information about specific health conditions and detail more information about risk monitoring and prevention.” from the report
Low attendance at meetings
minorResident and relative meetings took place each month on the units, but few people attended. Families may want to ask how their views are gathered if they cannot attend.
“However records indicated that they were not very well attended.” from the report
- 01How do you now assess staffing levels for a person with needs like my relative's, given that the previous dependency tool did not always reflect people's needs?
- 02Have all care plans been updated with consistent information about health conditions, risk monitoring and prevention?
- 03How will you record and share changes in my relative's care and changing needs?
- 04How can relatives give feedback if they cannot attend the monthly resident and relative meetings?
- 05What activities and support would be available for my relative's hobbies, interests and mental health needs?
This was an unannounced inspection covering all five questions and the overall rating, with the inspector reviewing seven care records and four staff files. This explanation was written from the published report of 15 December 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 Continuing Care
2 rated inspections over 3 years: the service has held its Good rating throughout.
- July 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Registered with the Care Quality Commission on 30 June 2014.
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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