30 November 2022
During an inspection looking at part of the service
St Mary’s House is a residential care home providing personal care for to up to 28 people. The service provides support to older people and those living with dementia. At the time of our inspection there were 24 people using the service.
People’s experience of using this service and what we found
At our previous inspection we found the systems to monitor and assess the quality and safety of the service were not robust. At this inspection we found that improvements had been made and professional input had been sought. However, governance processes had not identified all the issues we found on this inspection and actions required to remedy the identified concerns had not yet been completed. The registered manager assured us that action was being taken to address all the concerns.
People were protected from the risk of abuse because the provider had effective safeguarding systems in place. People received their medicines as prescribed. There were enough staff to safely support people.
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.
Staff were caring and promoted people's independence. People were treated with dignity and respect. People were supported to take part in activities and belong to the community of the service.
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 26 July 2022) and there were breaches of regulation relating to safe care and treatment and governance. 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.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 26 July 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when.
We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This inspection checked whether the provider had met the requirements of the Warning Notice in relation to Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 on a concern we had about the safety of the building.
This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contained those requirements. 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 remained requires improvement. This is based on the findings at this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Mary’s House on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.