CQC report explained · a residential care home
What the CQC found at St Mary's Residential Care Home
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 2021
Rated Good overall; inspectors found kind care and improved leadership, but safety still requires improvement.
This was an unannounced, focused inspection on 22 June and 7 July 2021. Inspectors spoke with five people, five staff members and six relatives. They reviewed care records, medicines records, staff files, training information and quality checks.
People were treated kindly and supported to keep their dignity, privacy and independence. Staff responded to people's needs in a timely way. Relatives were generally positive about the care and communication.
Safety was still rated Requires Improvement. Inspectors found a couple of medicines recording errors and duplicate protocols for medicines given when needed. Infection control was mostly satisfactory, but some staff training and individual risk assessments were not in place during the visit. The provider supplied evidence that these points were addressed afterwards.
The overall rating improved from Requires Improvement to Good. The home was no longer in breach of the regulations identified at the previous inspection. However, the inspection did not assess Effective or Responsive, so those ratings were carried over from an earlier comprehensive inspection.
Kind and respectful care
People were treated with kindness and respect. Staff supported privacy, dignity and independence, including keeping personal aids within reach.
“Since our last inspection, improvements had been made to ensure people were treated with kindness and respect.” from the report
Involvement in care
People were involved in decisions about their care. Care plans were updated using information from people and, where appropriate, their relatives.
“People were involved in decisions relating to the care and support they received.” from the report
Improved leadership
Management systems had improved since the previous inspection. Audits were being used to identify improvements, and leaders were available to staff.
“Audits were carried out on a regular basis.” from the report
Staffing and risk management
The manager reviewed staffing levels, and inspectors saw staff respond promptly. Risks were identified and care plans explained how to reduce harm.
“Risks to people were identified, assessments were in place and these were reviewed and updated regularly.” from the report
Medicines records
seriousInspectors found a couple of errors in medicines recording. They also found duplicate protocols for medicines given when needed, although the manager said these would be corrected.
“During our review of people's prescribed medicines, we found a couple of errors with recording.” from the report
Infection-control training and assessments
needs fixingStaff had not received practical training on putting on and removing protective equipment. Individual risk assessments for people at high risk had also not been completed during the inspection, although evidence was provided afterwards.
“The staff had not received training in donning and doffing but had been shown the information in a poster format.” from the report
Limited professional input
minorThere was limited input from other health professionals during the inspection because of COVID-19 restrictions. Contact was mainly by telephone.
“At the time of the inspection there was limited input from other health professionals this was due to COVID-19 and professionals entering the service.” from the report
- 01What checks are now in place to prevent errors in medicines recording?
- 02How have duplicate protocols for medicines given when needed been removed and kept up to date?
- 03Have all staff completed practical training on putting on and removing protective equipment?
- 04How are individual risk assessments for people at high risk reviewed and kept current?
- 05How will the home make sure people receive appropriate input from health professionals when face-to-face visits are limited?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 29 July 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.
What inspectors found, April 2020
St Mary's Residential Care Home was rated Requires Improvement; inspectors found caring staff and improved systems, but staffing, safety, dignity and management still needed urgent improvement.
This was an unannounced inspection on 30 and 31 January 2020. One inspector spoke with people, visitors and staff, reviewed care plans, medicines and recruitment records, and observed care and the home’s environment.
The home was not always safe. There were too few staff at night, leaving parts of the building unmonitored. Inspectors also found problems with falls management, medicines records and staff training for emergencies.
People were not always treated with dignity or supported to remain independent. Walking aids were moved out of reach, one person’s concern was handled poorly, and one person was supported to keep eating after clearly refusing.
The home was rated Good for Effective and Responsive, but Requires Improvement overall, for Safe, Caring and Well-led. Two previous breaches had been met, but four breaches remained or were identified, and the service had been rated Requires Improvement at its last two inspections.
Improved environment
Earlier environmental risks had been addressed. Radiators and pipework were covered, and water temperatures were controlled and checked.
“Radiators and exposed pipe work were now covered and they had installed a mixer valve system to the water to ensure it never exceeded recommended temperatures of 44 degrees.” from the report
Personalised care information
Care plans contained detailed information about people’s needs and preferences. The home also used pictures, life histories and communication prompts.
“Comprehensive care plans were developed from the information and the person's preferences once they had moved into the home.” from the report
Food and health support
People’s food preferences, allergies and special diets were recorded. Staff worked with specialist teams when people were at risk of malnutrition.
“The chef had a good understanding of how to support people with special diets including the fortifying of foods and drinks when people began to lose weight.” from the report
Complaints handled
The home had an accessible complaints procedure. Inspectors saw evidence of timely responses, investigations and apologies where needed.
“Investigations were completed and apologies given if required.” from the report
Too few night staff
seriousOnly two staff were usually on duty at night, leaving parts of the building unmonitored. There was also no suitably trained night staff member for some medicines, emergency first aid or fire evacuation duties.
“People were not suitably monitored and there were not enough staff present to offer support as required.” from the report
Falls and medicines risks
seriousFalls had increased and accidents had not been analysed for patterns or causes. Some medicines were given at the wrong time, and records did not always show refusals or changes.
“None of the accident records had been reviewed by the registered manager and there was no analysis to determine if there were any themes or trends” from the report
Independence and dignity
seriousWalking aids were sometimes placed where people could not reach them safely. Inspectors also saw a person’s refusal of food being ignored and found no dignity locks on communal bathroom doors.
“During the lunch time meal service one person was refusing their food but a staff member continued to support them to eat it.” from the report
Weak oversight
seriousThe manager had introduced new audits, but they had not yet identified the problems found during the inspection. There was no single live improvement plan covering all the actions.
“However, these systems were yet to embed and they had not been effective at identifying themes and trends in bad practice which had led to unidentified risk and undignified practice.” from the report
Recruitment records
needs fixingMost recruitment checks were in place, but one file lacked important employment history and verified references. The provider was given a recommendation to complete all required checks.
“As a consequence one file we looked at was missing key information including their full employment history and references that had been verified as truthful and accurate.” from the report
- 01How many staff are now on duty at night, and how do you ensure every part of the building is monitored?
- 02What changes have been made to analyse falls and prevent people falling again?
- 03How are medicines given at the correct times, and how are refusals or changes recorded?
- 04How do you make sure walking aids remain within people’s safe reach and that staff respect a person’s decision to refuse food or care?
- 05Has one complete improvement plan been created, and what evidence can you show of progress against the four breaches?
This was a planned, unannounced inspection covering all five key questions; the previous overall rating was Requires Improvement from 14 January 2019. This explanation was written from the published report of 25 April 2020 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 Residential Care Home
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at St Mary's Residential Care Home →
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementCaring: Requires improvementWell-led: Requires improvement
Read what inspectors found at St Mary's Residential Care Home →
- January 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2016
Registered with the Care Quality Commission on 31 October 2016.
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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