CQC report explained · a residential care home
What the CQC found at St Mary's House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Most earlier safety concerns had been addressed, but fire safety work was unfinished and prescribed creams had been left in an unsecured box. The home had enough staff, effective safeguarding systems and safe medicines processes.
- Effective?
- Good
- People's needs and dietary requirements were assessed, staff received suitable training, and legal authorisations and consent records were in place. Staff worked with healthcare professionals to support people's needs.
- Caring?
- Good
- This key question was not inspected during this focused visit.
- Responsive?
- Good
- This key question was not inspected during this focused visit.
- Well-led?
- Requires improvement
- The management team was committed to improvement and staff felt supported, but quality checks had not identified all outstanding safety actions. The improved monitoring systems still needed to become part of routine management.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found improvements in care and safety, but some building risks and management checks were still not fully addressed.
This was an unannounced, focused inspection on 30 November 2022. One inspector observed care, spoke with people, a relative and staff, toured the home, and checked care plans and quality records.
The home had improved since the previous inspection. People were protected from abuse, received medicines as prescribed, and there were enough staff. Care planning, staff training, consent arrangements and partnership working were rated Good under Effective.
The overall rating remained Requires Improvement. Safe and Well-led were also Requires Improvement because some building safety actions were unfinished and the home's checks had not found all the problems. The home was no longer in breach of the regulations identified at the previous inspection.
Safeguarding
The home had systems for reporting abuse and staff knew how to recognise and report concerns.
“Staff had access to information about how to protect people from harm.” from the report
Staffing
Inspectors found enough staff to meet people's needs. Recruitment checks were also carried out.
“Appropriate staffing levels were in place to meet the needs of people in the service.” from the report
Medicines
People received medicines as prescribed. Staff were trained and their competence was checked.
“Staff completed training to administer medicines and their competency was checked.” from the report
Effective care
The home improved its assessment, consent and healthcare arrangements. People's care plans included their needs, wishes and preferences.
“At this inspection we found that appropriate legal authorisations were in place.” from the report
Open culture
Staff said managers were accessible and supportive, and that concerns would be listened to.
“There was an open culture and staff were confident that any issues they raised would be listened to.” from the report
Unfinished fire safety work
needs fixingThe home had not fully complied with an Enforcement Notice from Suffolk Fire Brigade. Fire-retardant curtains had been ordered but were not yet fitted, and four radiators were uncovered.
“The service had not fully complied with the requirements of the Notice.” from the report
Unsafe storage of creams
needs fixingPrescribed creams were found in an unsecured box in a corridor. They were removed after inspectors raised the issue.
“We observed prescribed creams left in an unsecured box in the corridor.” from the report
Management checks
needs fixingThe home's monitoring systems had not found all the outstanding safety actions. Inspectors said these systems still needed to be embedded into day-to-day management.
“The provider's monitoring systems had not identified these.” from the report
Outstanding building work
minorSome smaller building improvements were still outstanding, including replacing a fogged dining-room window.
“Some improvements were still outstanding but these were of a more minor nature.” from the report
- 01Have the fire-retardant curtains now been fitted around both fire exits, and has the Enforcement Notice been fully complied with?
- 02Have the four uncovered radiators been removed or made safe?
- 03How are prescribed creams and other medicines now stored so that people cannot use them inappropriately?
- 04What checks are now used to make sure all safety actions are completed and recorded?
- 05What improvements have been made to the quality monitoring system since this inspection?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and the overall rating used the previous ratings for any key questions not covered. This explanation was written from the published report of 22 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.
What inspectors found, September 2022
Requires Improvement; inspectors found unsafe building conditions and weak oversight, although care, staffing and medicines were generally positive.
This was an unannounced focused inspection on 26 July 2022. Inspectors observed care, toured the home, reviewed records and spoke with staff, relatives and the manager. They were responding to information received, including concerns raised by the fire service.
Inspectors found several safety risks in the building. These included unsafe or missing window restrictors, an unsafe sash window, unprotected hot surfaces, poorly cleaned areas and overloaded electrical sockets. They also found that quality checks had not identified all these problems.
The home had enough staff, medicines were managed safely and people's care needs were met. However, some people were not supported in line with the Mental Capacity Act, including one person whose access was restricted while legal authorisation was still awaiting review.
The overall rating was Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were not given ratings in this report. The previous overall rating was Good, published on 2 December 2017.
Enough staff
Inspectors found staffing levels were sufficient to keep people safe and meet their needs. Relatives said staff did not seem rushed and spent time talking with people.
“There were sufficient staff to keep people safe and meet their needs.” from the report
Medicines
Medicines were managed safely. Staff were trained and their competence was checked.
“Staff completed training to administer medicines and their competency was checked.” from the report
Care and support
The report says the care met people's needs. Relatives described the staff as skilled and said people received the support they needed.
“The care people received met their needs.” from the report
Food and healthcare
People were offered meal choices and received help to eat and drink. Dietary needs and referrals to outside professionals were addressed.
“We observed the lunch time meal and saw that people were offered choices and received support as they needed.” from the report
Building safety
seriousInspectors found several risks that could cause injury, including unsafe windows, unprotected radiators, poorly assessed stair access and overloaded electrical sockets.
“We found two second floor windows which did not have window restrictors fitted.” from the report
Fire and cleaning risks
seriousSome areas were not adequately clean, and a tumble dryer filter was thick with fluff despite records saying it had been cleaned. Inspectors said this increased the risk of fire.
“We found that record had been completed but when we checked the filters, they were thick with fluff, demonstrating they had not recently been cleaned.” from the report
Restrictions and consent
seriousOne person's access to the main part of the building had been restricted while a DoLS application was awaiting review. Inspectors said this was not the least restrictive option.
“This was not the least restrictive option for the person.” from the report
Weak quality checks
seriousThe provider's governance systems did not identify all the safety issues found during the inspection. Some staff also said communication was not always clear.
“The providers governance systems were not effective in identifying health and safety concerns.” from the report
- 01What action has been taken to fix the unsafe windows, hot surfaces, stair access and electrical sockets?
- 02How do you now check that cleaning tasks, including tumble dryer filters, have actually been completed safely?
- 03How do you make sure any restriction on a person's movement is legally authorised, reviewed and the least restrictive option?
- 04What improvements have been made in response to the warning notices and the required action plan?
- 05How can relatives and staff raise safety concerns, and how are those concerns followed up?
The report says this was a focused inspection of Safe and Well-led, with other ratings carried over from the previous inspection, although it also records Effective as Requires Improvement and includes findings about consent and the building. This explanation was written from the published report of 8 September 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 St Mary's House
3 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- December 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2017GoodSafe: GoodEffective: GoodWell-led: Good
- July 2015
Registered with the Care Quality Commission on 1 July 2015.
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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