CQC report explained · a residential care home
What the CQC found at St Mary's
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found safe, responsive care but gaps in staff training, supervision, hydration checks and quality monitoring.
This was an unannounced focused inspection on 22 February 2023. One inspector spoke with six relatives and seven staff, and reviewed care records, medicine records, food and fluid records, staff recruitment files and management records.
The home was rated Good for Safe and Responsive. Inspectors found enough staff, safer recruitment, improved risk assessments, safe medicines management and person-centred care. Activities had also recently improved.
It was rated Requires Improvement for Effective and Well-led. Some staff training was out of date, supervision was not regular, fluid records were not properly reviewed, and the new quality system had not found this problem. The report says improvements had been made since the previous inspection and the home was no longer in breach of the earlier regulations, but Regulation 18 was breached at this inspection.
Enough staff
Inspectors found staffing levels were appropriate and recruitment checks were in place. Staff said there were enough people on shifts to meet residents' needs.
“Appropriate staffing levels were in place to meet the needs of people in the service.” from the report
Person-centred care
Care plans were detailed and reflected people's current needs. Staff were observed giving patient and attentive care.
“People received person-centred care from staff who knew them well and were responsive to their needs.” from the report
Improved activities
The home had recently employed two activity coordinators. Relatives reported that people were taking part in activities they enjoyed.
“Activities have really improved recently it is nice to see [family member] taking part in things” from the report
Safeguarding
Staff understood how to recognise and report abuse. The manager made appropriate safeguarding referrals and analysed accidents and incidents.
“Staff were aware of the signs of abuse and how to report safeguarding concerns.” from the report
Approachable management
Relatives and staff said they could raise concerns with the manager. The manager was described as open and honest about accidents and incidents.
“The registered manager had an open-door policy and relatives and staff said they could go to the manager any time if they needed.” from the report
Staff training and supervision
seriousSome refresher training was overdue. Staff had not received supervision as required by the home's policy, and the supervision records were poor quality.
“The provider had not ensured all staff were suitably trained or supported to perform their roles.” from the report
Hydration checks
needs fixingFluid charts were completed but senior staff did not regularly review them. Records showed that one person had not reached their ideal fluid intake for three days.
“Records reviewed did not identify that one person had not achieved their ideal fluid intake for 3 days” from the report
Quality monitoring
needs fixingThe new electronic quality system had not identified the problem with fluid checks. Inspectors recommended that the system be embedded so shortfalls are found sooner.
“There were some issues which the new quality monitoring system had not identified.” from the report
PRN medicines guidance
needs fixingMedicines were managed safely, but some instructions for medicines given when needed did not contain enough information for staff.
“Guidance for staff to administer medicines prescribed 'as and when required' (PRN) were not always in place.” from the report
Staff meetings
minorRegular staff meetings had not been held, so staff did not have a regular arranged opportunity to share concerns or views.
“Regular staff meetings had not been held to allow staff to voice their concerns or views within the service.” from the report
- 01Which staff still need refresher training, and when will all overdue training be completed?
- 02How often will staff receive supervision, and how will you check that supervision records are complete and useful?
- 03How do senior staff now review fluid charts and respond when someone is not drinking enough?
- 04What information is included in the updated PRN medicines protocols?
- 05How will the electronic quality monitoring system identify missed checks and other shortfalls promptly?
This was a focused inspection checking improvements in Safe, Effective, Responsive and Well-led; the Caring rating was not given in this report. This explanation was written from the published report of 21 April 2023 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, July 2022
Rated Requires Improvement; inspectors found kind care, but important safety, consent, care planning and management systems were not reliable.
This was an unannounced inspection on 25 and 31 May 2022. Inspectors spoke with people, relatives, staff and professionals. They reviewed care files, medicines records, recruitment, training and quality checks.
The home was rated Good for Caring. People were treated with kindness, dignity and respect. Medicines were managed safely, recruitment checks were completed, and people were supported with food, drink and contact with family and friends.
The other four areas were rated Requires Improvement. Inspectors found that risks, care plans and records were not always up to date. The principles of the Mental Capacity Act were not always followed, and people and relatives were not consistently involved in decisions.
The home was newly registered and this was its first inspection. The provider was asked for an action plan, and the CQC said it would monitor progress and take further action if needed.
Kind and respectful care
People received compassionate care and staff respected privacy, dignity and independence. People's individual choices, such as the gender of their carer, were acted on.
“People received kind and compassionate care. We observed warm interactions between people and staff.” from the report
Medicines
Medicines were received, stored, given and returned safely. Staff who administered medicines were trained and their practice was checked.
“Medicines were safely received, stored, administered and returned to pharmacy when they were no longer required.” from the report
Food and drink
People had choices that met their dietary needs and received support where needed. Mealtimes were not rushed and snacks and drinks were available.
“Mealtimes were a pleasant experience with caring and supportive interactions observed from staff.” from the report
Family contact
People were supported to keep in touch with family and friends through visits, phone calls and video calls.
“People were supported to maintain contact with family and friends. This included phone calls, video calls and visits.” from the report
Risks and care records
seriousSome risks, including falls, choking and challenging behaviour, did not have current assessments or clear guidance for staff. This was a safety breach.
“People's risks were not managed after they were identified in assessments.” from the report
Consent and best interests
seriousBest-interest decisions did not always involve families or relevant professionals. Staff were unclear about the Mental Capacity Act and restrictions on people's freedom.
“Best interest decisions had been made without the involvement of relevant external professionals and families around important decisions that people could not give informed consent to.” from the report
Staffing and safeguarding
needs fixingRelatives and staff reported that staffing levels were sometimes insufficient, leaving little time for meaningful engagement. Some staff lacked knowledge about recognising, responding to and reporting safeguarding concerns.
“Staff told us, "we are really rushed" and "everything gets done, we just don't have time to speak to them [people]".” from the report
Activities and personal planning
needs fixingActivities did not always reflect people's interests, and some people did not know activities were taking place. End of life wishes were not always discussed or recorded.
“Some people in the service did not know activities were taking place and told us, "I would have gone, I like skittles, but I did not know it was happening.” from the report
Leadership and oversight
seriousAudits did not reliably identify problems with records, risks or incidents. There was little evidence that accidents and incidents were investigated properly or used to improve care. This was a governance breach.
“The governance framework did not promote continuous learning to improve the service.” from the report
- 01Have all current falls, choking and behaviour risks been reassessed, and do care plans now give staff clear instructions?
- 02How are you making sure best-interest decisions involve relatives and relevant professionals when a person cannot consent?
- 03What has changed in staffing levels since the inspection, and how do you ensure people have time for meaningful activities and conversation?
- 04How are you involving people and relatives in care planning and informing them about changes in care?
- 05What checks now make sure incidents are investigated, lessons are recorded and improvements are followed through?
This was an unannounced first inspection of the newly registered home and covered all five CQC questions, including infection prevention and control measures. This explanation was written from the published report of 21 July 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
4 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021
Registered with the Care Quality Commission on 6 April 2021.
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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32 live-in carers within about an hour of North Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,300 a week. 29 can care for a couple. 11 years' experience on average.
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.