St Mary's

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 6 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. The assessment of these areas indicated areas of concern since the last inspection. We found a breach of the legal regulation in relation to good governance. The learning culture was not always robust. Themes and trends were not always identified through the provider’s systems currently in place. Staff meetings took place. However, outstanding concerns were not discussed. Although regional manager meetings took place there was no record about what was discussed during these meetings. This meant we could not be assured areas of concern were identified and managed. We also found a breach of the legal regulation in relation to need for consent. Clear and complete records were not always available to show how people's capacity was assessed. Assessment of people's capacity to make decisions where restrictions had been applied were not always completed. Where people may have regained capacity, decisions made in their best interests were not always reviewed in a timely way. We also found a breach of the legal regulation in relation to safe care and treatment. Not all risks for people were identified and recorded in relation to their care and support needs to ensure their safety and wellbeing. Systems were not always in place to ensure people's assessed needs were care planned. This meant people were at risk of receiving inappropriate care and support. Systems and processes were not in place to ensure the safe management of medicines. Where people were prescribed 'as required' or variable dose medicines, clear guidance was not always recorded to help make sure staff administered an appropriate dose of people's medicines when needed.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Comments about management were mixed. Very few people knew the name of the manager. Everyone said that if they had concerns, they would know who to speak to, be it going to the manager’s office or just telling staff. A family member told us, “If I had any concerns they would act on it, I am sure." They added, “If not I would go to the main office.” Another family member said, “I was not happy recently, when I was told [name of relative] couldn’t have a bath, due to staffing issues. When I left later, I saw 3 staff together, braiding hair. It made me so mad, so I confronted them. They were very sorry and in fairness [name of relative] has had a bath regular since.”

Staff told us they discussed accident and incidents in staff meetings. However, they were unable to give any examples of this and there were inconsistencies in how staff meetings were held. Staff felt confident that they could raise any concerns, and these would be dealt with. The regional manager told us clinical governance audits were completed by the registered manager and sent each month to them. This meant that the regional manager had oversight of themes and/or trends identified within the service, for example accidents and incidents and people’s weight loss. The regional manager told us they visited the service weekly and completed a walkaround. However, there was no evidence to support this. The registered manager told us they discussed areas such as pressure sores in handover meetings with staff and accident and incidents at department meetings. However, there was no evidence to show they discussed and reviewed themes and trends or did reflective practice. This meant that changes could not be implemented to improve care for others.

Themes and trends were not always identified through the provider’s systems currently in place. Staff meetings took place. However, outstanding concerns were not discussed. Although regional manager meetings took place, there were no records about what was discussed during these meetings. This meant we could not be assured areas of concern were identified and managed. The regional manager told us they visited the service weekly and completed a 'walk around'. However, there was no evidence to support this.

People told us they were supported to see GPs and other professionals when needed.

The registered manager understood the importance of ensuring a safe transition when people were moving in to or on from the service. They were able to give examples of how they had recently supported someone to transition back into independent living.

Feedback from professionals was mostly positive. One district nurse said, “I have been coming for a long time and they usually listen to my advice.” The registered manager was welcoming of advice and had accepted an offer from the local Medicines Optimisation team to attend the service for a support visit. Staff and people spoken with raised no issues about accessing professionals including seeing GPs. The local authority had received four individual safeguarding concerns from the service. These were closed with no further action required. These included potential concerns identified by the service about moving and handling, and medication.

The service had referred people to specialist services and professionals to ensure their care and treatment was effective. Admission assessments were completed prior to moving to the service.

People felt safe at St Mary’s. Comments from people included, “I definitely feel safe. Staff are as honest as they can be”, “Absolutely I feel safe. Staff can’t do enough”, “I am fine here yes, I definitely feel safe” and “I am well looked after here. Staff are very helpful.” Comments from relatives included, “Yes, I definitely feel [name of relative] is safe here. Staff are good and we have no concerns.”

During the inspection we spoke with the registered manager, regional manager, senior care assistant, 3 care staff and the activities coordinator. Staff felt confident they kept people safe. They told us they had received safeguarding training and were confident to report any allegations of abuse and that this would be addressed. Staff told us they understood the types of abuse and who to escalate these to.

We observed that staff were kind and engaging with people. We observed staff demonstrating gentleness and there was a genuine caring relationship from staff to people. However, we observed a staff member asking people about their medicines in a non-discreet manner. One person was clearly embarrassed and walked away. We also witnessed a potential trip hazard in the service from a resident’s dog that was allowed to wander freely around, with no risk assessment seen.

Assessment of people's capacity to make decisions where restrictions had been applied were not always completed. Where people may have regained capacity, decisions made in their best interests were not always reviewed in a timely way. For example, forms which recorded a person’s wishes for their future care in the event of their incapacity did not always align with people’s capacity records. There was minimal evidence to support learning lessons from safeguarding concerns which had occurred at the service. For example, no themes of trends were identified resulting in a lack of changes to improve care for others.

We received mixed feedback from people about their involvement in care plans.

The registered manager told us people and their relatives were involved in their care plans. There was an allocated person who updated care plan and risk assessments. Staff we spoke to understood their responsibilities to keep people safe. They were able to explain how to mitigate risks to people they supported.

We observed staff were task orientated. Whilst people were supported safely, we observed staff did not always spend time sitting and talking to people. However, we observed activities being undertaken in the main lounge and there was a sense of engagement by people and staff.

Not all risks for people were identified and recorded in relation to their care and support needs to ensure their safety and wellbeing. For example, risks relating to allergies and people who had epilepsy were not identified, and records did not contain enough detail to mitigate the risk or potential harm for people using the service. Systems were not always in place to ensure people's assessed needs were included in their care plan. This meant people were at risk of receiving inappropriate care and support. Weight records were not always completed or reviewed effectively in line with people’s care plans. Care plans contained conflicting information. For example, one person’s care plan recorded the person required a regular consistency diet, and then later recorded the person was at risk of choking, and required meals to be fortified. There was a business continuity plan in place which was clear, concise and structured for staff to follow. Critical stage plans were also in place. This meant the provider had made plans to keep people safe in the event of an unexpected event.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed feedback from people around staffing levels.

Staff we spoke with felt there was sufficient staff on duty to meet people's needs. They told us they felt supported by the management and were happy with the training they received.

Observations made by the assessment team suggested there were sufficient staff to support people safely.

At the last inspection the provider was in breach of the regulation of staffing as the provider had not ensured all staff were suitably trained or supported to perform their roles. We found staff had completed their mandatory training. However, staff had not received catheter care training, one person's appraisal mentioned they would like to be more up to standard with catheter care. We raised this with the registered manager who confirmed catheter care training had been booked. Staff we spoke with had knowledge of the risks associated with catheters and we were assured people were adequately supported with their catheter care. Staff told us they felt supported and were supervision and could access support as and when needed. However, supervision records we reviewed were often generic or group supervisions and were not giving people regular feedback on their performance. Robust recruitment processes were in place and carried out. The provider had a dependency tool in place, which calculated people’s needs and was used by the registered manager to access how many staff were needed. The registered manager had recently taken on bank staff to increase care hours.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

There was a mixed response from people in respect of whether they were aware of what medication they were taking and why. Comments included, “Staff look after all my medication. I just take them”, “Staff provide me with any medication, but I don’t know what they are for”, “I know what I take and why” and “I get help with my medication and I know why I take them.” Medication was controlled by staff and three people were being given their medicines covertly [disguised in food or drink], however appropriate documentation was not in place for this to be carried out safely.

Systems and processes were not in place to ensure the safe management of medicines. Staff practice was not always in line with best practice guidance. For example, staff did not change their gloves when tablets had been put into people’s mouth by hand. There was no recording system for administration of prescribed thickeners and stock levels were not always accurate. This meant we could not be assured that medicines had been given as signed for by staff on the medicine's administration record. Medication audits had not been used effectively to identify and address these concerns. Where staff had administered 'as required' medicines, they did not always record why they had administered the medicine or that it had been administered appropriately. Sufficiently robust systems were not in place to monitor medicines in stock and any unused medicines that needed to be returned to the pharmacy. Medication reconciliation from discharge summaries was not always found to be accurate and align with the Medicines Administration Policy (MAR). Three people were being given their medicines covertly [disguised in food or drink] and appropriate documentation was not in place for this to be carried out safely. Best practice guidance states prescribed transdermal patches should be rotated to different application sites to mitigate the risk of skin irritation. Prescribed transdermal patch rotation was not being used. This means staff practice was not always in line with best practice guidance.