What the CQC found at St Marys

Inspectors saw staff building warm relationships with people. Staff were calm, patient and responsive, including when people were anxious or repeatedly asked questions.

“Our observations of staff engagement with people, found staff showed a warm affection and respect in the way they spoke with people.” from the report

The home had enough staff on the inspection day, with staff responding promptly to requests. Risks such as falls, nutrition, moving and handling and skin care were assessed and reviewed.

“People were supported by sufficient staffing levels that were deployed appropriately.” from the report

People had choices of meals and drinks, with individual dietary needs supported. Staff worked with healthcare professionals and followed their recommendations.

“People received sufficient to eat and drink and meals provided people with choice and met their individual needs and preferences.” from the report

The home had addressed the previous breach about quality and safety checks. Environmental repairs and improvements to care planning had also been made.

“At this inspection we found systems in place to monitor quality and safety was fully implemented and working well.” from the report

Care plans included people's routines, histories, preferences, communication needs and cultural or religious needs. People were supported to make choices about daily life.

“People's support plans demonstrated how their diverse needs, including their religious and cultural needs and preferences, had been considered and planned for.” from the report

Some protocols for medicines given as needed did not state the maximum dosage. The manager corrected this immediately during the inspection.

“On the whole these had been completed appropriately but the maximum dosage was not recorded in some.” from the report

Two new staff had completed induction but had not yet received training from the provider. Training was arranged within four days of the inspection.

“We identified two new staff had received an induction but had not received any training.” from the report

Capacity assessments and best-interest decisions were recorded, but they were not routinely reviewed. The management team agreed to include these checks in monthly care plan reviews.

“We noted however, MCA and best interest decisions were not being routinely reviewed and discussed this with the management team.” from the report

Activities and equipment were available, but one person and a relative said there was not enough to do or enough stimulation. The home did not consistently record whether people took part.

“One person and a visiting relative told us they felt there was a lack of activities and stimulation.” from the report

There was no ongoing action plan showing how identified shortfalls were being managed or how the service was developing. The manager was also providing care, which limited time in the office.

“There was not an ongoing action plan to show how the service was progressing and developing, or how any shortfalls identified through internal monitoring were being managed.” from the report