22 February 2023
During an inspection looking at part of the service
St Mary's is a residential care home providing personal and nursing care for up to 47 people. The service provides support to people with dementia, mental health, older people and younger adults. At the time of our inspection there were 41 people using the service in one adapted building.
People’s experience of using this service and what we found
The provider had not ensured all staff were suitably trained or supported to perform their roles. Some staff required refresher training to ensure they had the knowledge and skills to safely meet people’s needs. Staff did not receive regular supervision however; staff felt the registered manager was supportive and approachable.
Medicines were managed safely however, guidance for staff relating to medicines which were prescribed on an ‘as and when required basis’ (PRN) were not in place. We have made a recommendation about this.
Records relating to people’s fluid intake were not regularly reviewed to ensure people had enough to drink. We have made a recommendation about this.
Care plans and risk assessments were person centred and reflective of people's current needs.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
There were enough staff. Staff were recruited safely and received an induction to ensure they had the skills and knowledge to undertake their role.
Regular activities were carried out to promote social inclusion.
Systems were in place to protect people from abuse. Staff demonstrated a good level of understanding in relation to safeguarding. Appropriate referrals to the local safeguarding team had been made. Relatives and staff spoke positively about the registered manager and felt able to raise concerns and were confident that these would be addressed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 20 July 2022) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
At our last inspection we recommended that the provider made improvements in relation to safeguarding, staffing levels and staff support and supervision. At this inspection we found the provider had made improvements on staffing levels and safeguarding but had not made improvements in relation to staff supervision.
Why we inspected
We carried out an unannounced inspection in May 2022 and found improvements were needed. We undertook this focused inspection to check the service had followed their action plan and to confirm improvements were made. This report only covers our findings in relation to the Key Questions safe, effective, responsive and well-led which contain those improvements.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.