CQC report explained · a nursing home
What the CQC found at St Mary's Nursing Home Margaret Street Stone
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Rated Requires Improvement; inspectors found caring staff and safe medicines management, but some environmental risks and weak quality checks needed action.
This was an unannounced inspection on 7 and 8 December 2023. Inspectors spoke with people, relatives, staff and professionals. They observed care and checked care records, medicines, recruitment files and management records.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. Hot radiators and pipes, windows on upper floors and an unlocked cupboard containing hazardous items created risks. There were also some gaps in records for medicines given when needed. The home acted quickly when inspectors raised these concerns, and no one had been harmed as a result.
People and relatives said they felt safe and well cared for. Inspectors found enough staff, suitable recruitment checks, a clean home, generally safe medicines management and an open, supportive culture. However, the quality assurance systems had not found or dealt with some risks before the inspection.
People felt safe
People and relatives consistently said they felt safe and well looked after. Staff understood safeguarding and knew people's needs.
“People and relatives consistently felt safe living in the home and felt positive about the care they received.” from the report
Enough suitable staff
Inspectors found enough staff to keep people safe. Recruitment included checks on employment history, references and criminal records.
“People were supported by enough suitably recruited staff.” from the report
Clean environment
The home was clean and tidy, with no unpleasant smells. Inspectors saw domestic staff cleaning during the day.
“The home was clean and tidy, with no malodours.” from the report
Positive culture
People, relatives and staff spoke very positively about the management team. People felt able to raise concerns and believed they would be acted on.
“The culture of the service was open and inclusive.” from the report
Learning from incidents
Accidents and incidents were reviewed, with actions recorded. The home also looked for patterns and retrained staff when serious incidents occurred.
“There was an analysis of accidents and incidents monthly to check if there were any trends and further improvements which could be made.” from the report
Hot surfaces
seriousSome radiators and pipes were not covered or temperature-limited. This created a possible burns risk.
“Hot radiators and hot pipes were not always covered, or temperature limited, to ensure they could not pose a burns risk to people.” from the report
Upper-floor windows
seriousSome windows on upper floors did not have suitable restrictors. This left people at risk of falling from height.
“Windows on upper floors were not always appropriately restricted which left people at risk of falling from height.” from the report
Quality checks missed risks
seriousThe home's checks had not fully identified or dealt with environmental risks, access to hazardous items and some medicines recording omissions. This led to a breach of Regulation 17.
“Quality assurance systems in place had failed to fully identify and act on concerns with hot radiators and pipes, windows not being appropriately restricted, access to hazardous items and some minor medicines omissions.” from the report
Medicines records
needs fixingThere were some omissions in information and records for medicines given when needed. Inspectors said no one had been harmed and immediate action was taken.
“Some minor improvements were needed regarding documentation around 'when required' medicines and the support being offered to 2 people around some medical equipment.” from the report
- 01What action has been completed to cover or temperature-limit the hot radiators and pipes?
- 02How are upper-floor window restrictors now checked and maintained?
- 03How is the cupboard containing hazardous substances and items kept locked?
- 04How are medicines given when needed recorded, including the reason and outcome?
- 05What action plan was sent to CQC, and what checks now show that the previous risks have stayed fixed?
This inspection focused on risks linked to Safe and the management systems linked to Well-led; the report does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 16 February 2024 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, January 2022
Rated Good overall, with Outstanding responsive care and strong support for people's choices, relationships and end-of-life wishes.
This was an unannounced inspection on 10 November 2021. Inspectors spoke with people living in the home, relatives, staff and visiting professionals. They also reviewed care files, medicines records, recruitment files, audits and other records.
The home was rated Good for Safe, Effective, Caring and Well-led. Inspectors found people were protected from abuse, received medicines safely, had enough trained staff and were supported with food, healthcare, consent and infection control.
Responsive was rated Outstanding. Inspectors found especially strong support for end-of-life care, communication, activities, personal interests and relationships with families. The home also adapted its approach during the COVID-19 pandemic to help people stay connected.
The overall rating remained Good, the same as at the previous inspection published in September 2019. Responsive improved from Good to Outstanding, while the other four ratings stayed Good.
End-of-life care
The home helped people and families discuss and record end-of-life wishes. Families were supported to spend meaningful time together, including sharing meals and staying overnight.
“People told us end of life care was exceptional, they told us they received kindness, time together and spiritual support towards the end of life.” from the report
Communication support
People's communication needs were recorded and the home provided packs with games, puzzles and communication aids to help people and relatives interact.
“The service took innovative steps to meet people's information and communication needs.” from the report
Activities and relationships
People were supported to continue hobbies, attend places of worship and take part in activities that mattered to them. The home also found ways to keep families involved during the pandemic.
“People were supported to participate in activities which reflected their social interests.” from the report
Personalised care and choice
People were involved in care planning and could make choices about daily routines, meals, where to eat and how much support they received.
“Choices were sought over all aspects of daily life and decisions respected.” from the report
Leadership and learning
Inspectors found visible leadership, good teamwork and a culture where feedback, incidents and concerns were used to improve care.
“There was a clear culture of continuous learning and improving care.” from the report
Planned refurbishment
minorThe home was due to have work carried out on floors and skirting boards. The manager said this had been scheduled, but the report does not confirm when it would be finished.
“The home was due some refurbishment work to the floors and skirting boards.” from the report
- 01Has the planned refurbishment of the floors and skirting boards been completed?
- 02How would you support my relative's particular communication needs, and could we use the communication packs?
- 03How would you record and follow my relative's end-of-life wishes and involve our family?
- 04How would my relative continue their hobbies, religious activities and important relationships?
- 05How would you keep us informed about changes in our relative's health or care?
This unannounced inspection considered all five CQC key questions and included infection prevention and control arrangements, with the overall rating remaining Good. This explanation was written from the published report of 8 January 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 Nursing Home Margaret Street Stone
7 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Requires improvement
Read what inspectors found at St Mary's Nursing Home Margaret Street Stone →
- January 2022Goodstayed GoodSafe: GoodWell-led: Good
Read what inspectors found at St Mary's Nursing Home Margaret Street Stone →
- September 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- October 2016Requires improvementup from InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 4 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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