St Mary's Court

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 identified 1 breach of the legal regulations. The provider had not always managed risks to people’s safety effectively or acted promptly to learn from safety incidents. We received mixed feedback about staffing levels and staff knowledge. The provider’s processes for responding to safeguarding concerns and communicating with people, their relatives and other health professionals were not always robust. People’s medicines were administered by trained staff; however, medicines systems and practices were not always effective. The provider completed environmental and equipment safety checks; however, infection control processes did not always accurately identify concerns.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Concerns about people's health and safety were not always promptly identified and actioned to ensure lessons were learnt. People and their relatives told us issues had to be raised repeatedly before they were addressed appropriately. Comments included, "We've tried to address the issue but nothing seems to happen," "[Concern] has been pointed out but it's still happening" and " We had a problem with [person's] catheter. I had meeting about this and the then manager said, 'we're on this' but still we had problems.”

Staff told us they knew how and where to record accidents and incidents. However, we found some incidents had not been documented accurately. This meant there was a risk learning may not be identified in order to minimise the risk of a reoccurrence. The manager told us they were continuously discussing incidents and accidents with staff during their daily morning meetings. Following our feedback, the manager confirmed they would arrange additional training around the appropriate recording of incidents.

The provider's processes for addressing and learning from safety concerns were not always robust. For example, where the management team had consistently identified concerns with the completion of people's daily monitoring records, such as fluid intake and repositioning support, it was not clear how staff were being supported to make the necessary improvements to ensure people received safe care. Records showed the same concerns being raised repeatedly. The provider told us they were improving how lessons learnt were recorded and shared and where concerns were continuing to be identified this would be addressed with staff through supervisions, retraining and closer monitoring.

People had information about their health and support needs in their care plans which could be shared with relevant health professionals when required. However, we received mixed feedback about whether information was updated following transitions between services and this meant people may not experience continuity of care. One relative told us, "The care plan had been shown as reviewed twice since [person] returned from hospital, yet the information on medicines and nutritional support had not been changed to show the current situation."

The provider told us there was an experienced nursing team at the service who understood people’s needs and ensured relevant information was shared with other healthcare professionals to ensure continuity of care. Staff confirmed they understood the importance of sharing up to date information when required such as during hospital admissions and discharges.

We received mixed feedback from the health professionals we spoke with about how well the service communicated with them to ensure information was transferred across services when required.

The provider's processes for ensuring continuity of care across services were not robust as information in people's care records was not always up to date and accurate. The provider told us they were addressing this concern by undertaking a full review of care plan documentation to ensure information was detailed and up to date.

We received mixed feedback from people and relatives about how well people were protected from the risk of harm or neglect. Concerns around staffing levels, staff knowledge and competency, inaccurate documentation, and a lack of effective communication from the provider were identified as concerns which impacted the safety of people's care.

Staff knew how to report safeguarding concerns. One member of staff told us, "We should report our concerns to the manager. We can also report our concerns directly to the local authority, safeguarding team or the CQC." At the time of the assessment, the provider was working with the local authority to manage ongoing safeguarding concerns in the service. The provider told us they were completing internal investigations and sending additional information and updates to the safeguarding team as required in order to address these concerns and make improvements.

We observed people receiving safe care from staff during the assessment, with no safeguarding concerns identified.

The provider's safeguarding processes were not always robust. Information relating to incidents was stored in the provider's safeguarding file; however, we found not all relevant records were kept together and this meant it was not always clear where investigation reports and outcomes were recorded or what actions had been taken. Incidents had not always been accurately documented as safeguarding concerns. The provider was aware of these concerns and were making improvements to their processes at the time of the assessment. This included documenting safeguarding concerns via an electronic service monitoring system which enabled them to review the status of safeguarding concerns more accurately. The provider told us they would also review their paper based documentation to ensure all relevant documentation was in place.

People and relatives told us they did not always feel risks were understood or well managed. Comments included, "Staff do find [person's] behaviours difficult. I found they had shut [person's] door and their curtains were drawn. I feel they just want to quieten person down", "I’ve been told [person] has been referred to the SALT [speech and language therapist] but I’m not confident staff understand what they should be doing, I’ve seen drinks both thickened and not thickened" and "[Person's] agitation got worse, but staff didn’t know how to deal with it."

The service had experienced a period of changes in staffing under the new provider, with the loss of some experienced staff and a number of new staff employed. Agency workers were also deployed across the service to cover staff vacancies. These changes in staffing had impacted on how well staff understood people and their individual risks. Staff did not always have sufficient guidance in place about how to manage risks to people safely and supportively. The provider told us they were making improvements to the risk assessment and review process to better involve people and those important to them and ensure staff were provided with clear up to date guidance to support their working practices.

We observed staff supporting people safely with their nursing care needs and mobility support during our assessment. No concerns were identified with staff practices during our observations.

The provider's processes for managing risk were not robust. People's care plans and risk assessments did not contain enough detail about the risks to their health and safety or how to minimise these. Staff did not have detailed guidance about what to do if something went wrong. The provider had not ensured people's risk assessments had been updated to reflect changes in their needs and this meant some information was contradictory and inaccurate.

People had appropriate equipment in place to meet their needs safely and the environmental risks of the service had been considered by the provider. However, during the site visit we found 2 cupboards containing cleaning products hazardous to people's health, had been left unlocked. This placed people at risk of harm.

Staff understood the importance of checking people's equipment prior to use and the provider completed regular health and safety checks to monitor any environmental risks. The environment of the service and some of the fixtures were in need of refurbishment. The provider confirmed a refurbishment plan was in place for the service and provided a copy of this to demonstrate timescales for completion.

We found the fixtures and fittings of the building were worn in places and we observed staff had not always locked hazardous materials away as required. We raised these concerns with the provider, who responded promptly, speaking to staff and ensuring cupboards were locked. We observed staff supporting people safely with their mobility equipment and aids.

People had personal emergency evacuation plans [PEEPs] in place to provide guidance on what support they would require in the event of a fire. The provider completed health and safety and environmental audits of the service to identify any concerns. Actions from these audits were incorporated into their ongoing service development plan enabling them to monitor the improvements needed.

People and their relatives told us staff were not always available when needed and raised concerns about the high turnover of staff. Comments included, "I’ve seen them struggling staff-wise. I found [person] in bed with a plate of food in front of them, but no staff around", "Sometimes it is impossible to find staff to talk to. There is not enough checking on people, I could be there three hours and see no staff", "I have recently noticed a reduction in the number of staff about, and a lot of new faces" and "There are not enough staff, it’s hard to get hold of anyone for answers." People did not always receive their care promptly. One relative told us, "There's so many different staff that keep changing it's difficult to keep up. When [person] pressed the buzzer the other day someone came and switched it off, then walked out. [Person] needed the toilet." Another relative said, "I have often found [person] in need of changing, and I have had to do it sometimes. It is hard to get hold of staff." We received mixed feedback about how well staff understood people's health conditions and individual needs, with some relatives raising concerns about staff's understanding of dementia and support for people experiencing distress.

Staff told us there had been a period of change and instability in staffing levels and knowledge. However, the staff we spoke with said this was now improving as new staff settled into the service and more regular agency workers were employed. Staff told us they had received adequate training for their roles. However, we found staff were not receiving regular one to one supervisions. This meant it was difficult to see how their learning and development was being supported to ensure safe working practices were embedded. The provider told us they were continuously recruiting to ensure vacancies were filled and confirmed the new management team were prioritising staff learning and supervisions to ensure appropriate support was in place going forward

We observed several people waiting for personal care support during our assessment; however, this was addressed by the manager when identified. Generally, we found staff were available when required and people's call bells were answered promptly.

The provider's processes for recruiting staff were not always robust. Employment checks had not always been completed accurately prior to new staff starting work. For example, we found gaps in applicant's employment histories and references were not always in place for applicant's previous care positions. The provider's processes for supporting staff were not always effective. Staff did not receive regular supervisions or appraisals and there was a lack of ongoing monitoring of staff performance and development. The new manager was in the process of addressing these concerns at the time of the assessment, completing new supervisions with all staff and implementing a planning schedule for future supervisions.

We received mixed feedback from people and relatives about the cleanliness and hygiene of the service. Relatives identified concerns with "unsatisfactory bedding and dirty linen left in a pile in the room", "sick on the bed" and "staff who drained [person's] commode in the wash basin". However, other relatives told us, "It is always clean and tidy, the whole home is spotless" and "The environment is very clean and [person's] room is always spotless." People's relatives told us they had seen improvements in cleanliness and hygiene in recent weeks and their concerns had been addressed when raised.

Staff had received infection prevention and control training and told us they had appropriate personal protective equipment [PPE] available to use. Staff knew how to access up to date information about infection prevention and control. The provider told us they discussed any infection or hygiene concerns with staff during their daily meetings to ensure prompt actions were taken.

We found some items and surfaces within the service were worn and this meant it was difficult to ensure they were clean. We also found walls and door handles which were unclean. This increased the risk of infection to people. We shared our concerns with the provider who responded promptly to replace items and arrange deep cleaning of the relevant areas.

The provider had infection prevention and control processes in place; however, we found these were not always operating robustly. For example, despite regular infection control audits being completed, we found unclean and worn cleaning equipment such as toilet brushes and mop buckets. These had not been identified as a concerns within the audits. The provider had an up to date infection prevention and control policy in place and there was a process in place to ensure staff received relevant infection prevention and control training.

During our assessment, we found people were being supported to take their medicines safely and no concerns were raised with how medicines were being administered. One relative told us, "The management of medicines has always been very good." People were supported to take as and when required [PRN] medicines such as pain relief. However, we received some mixed feedback about how well this was monitored to ensure people were supported to manage their pain effectively. One relative told us, "Pain relief is an issue, staff will look in and say 'how are you' and accept [person] saying, 'fine thanks', they should ask if [person] has any pain or would like any paracetamol. [Person] is supposed to be asked routinely by the nurse doing the meds round, but I’ve seen the trolley go by, without [person] being asked.”

The staff we spoke with were knowledgeable about people's medicines and how to support them safely. Staff who were administering medicines were appropriately trained. The provider told us they completed competency checks and medicines audits to monitor practices and identify areas of improvements

Prior to the assessment, there had been a number of concerns raised around the impact of staffing inconsistencies and poor communication on the safe management of medicines. This had resulted in an increase in errors. During this assessment, we found the provider was making improvements with issues identified and an ongoing action plan was in place. The provider had an up to date medicines policy and processes to ensure medicines were ordered, stored and disposed of appropriately. Medicines administration records were in place and people's controlled drugs were managed safely. During the assessment we identified some concerns with the provider's system for tallying stock balances. We gave this feedback to the provider who responded promptly, speaking to the relevant staff to ensure consistent approaches were embedded.