Archived: St Marys Nursing Home

Updated 10 January 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 5 and 6 December 2016 and was unannounced. The inspection was undertaken by an adult social care inspector. A local authority contracts officer was also carrying out an assessment of the home on the days we were inspecting the service.

Prior to the inspection visit we gathered information from a number of sources. For instance, we looked at the information received about the service, including the provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We also looked at notifications sent to the Care Quality Commission by the registered manager.

At the time of our inspection there were 28 people using the service. As part of this inspection we spent time with people who used the service talking with them and observing the care and support provided by staff, this helped us understand the experience of people who used the service. We also looked at documents and records that related to people’s care, including two people’s care records. The local authority contracting office also gave us feedback from two care files they looked at. We spoke with seven people who used the service and three visitors. We also spoke with the tissue viability nurse who was visiting someone using the service.

During our inspection we spoke with the registered manager, the regional manager, two nurses, two care workers and the administrator, as well as speaking with the activities co-ordinator and kitchen staff as they went about their work. We also looked at records relating to staff and the management of the service. This included reviewing staff rotas, the training matrix, five staff recruitment and support files, medication records and quality audits. The local authority contracts officer also shared information they found during their audit of the service.

Updated 10 January 2017

The inspection took place on 5 and 6 December 2016 and was unannounced on the first day, which meant no one connected to the home knew we would be inspecting the service. This was the first inspection since the care home was registered under this provider in November 2015.

St Mary's Nursing Home is situated near the centre of Doncaster. It can accommodate up to 56 older people in two separate units, however one of the units is closed. The remaining unit provides accommodation for people who require personal or nursing care. At the time of our inspection 28 people were living at the home.

The service had a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People who used the service, and the visitors we spoke with, told us they were happy with how care and support was provided at the home. They spoke positively about the staff and the way the home was managed. We observed staff supporting people in a caring, responsive and friendly manner. They encouraged people to be as independent as possible while taking into consideration any risks associated with their care.

We saw there were systems in place to protect people from the risk of harm. Staff we spoke with were knowledgeable about safeguarding people and were able to explain the procedures to follow should an allegation of abuse be made. Assessments identified any potential risks to people and plans were in place to ensure people’s safety.

We found medicines were stored safely and procedures were in place to ensure they were administered correctly.

The service was meeting the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The staff we spoke with had received training in these subjects and people who used the service had been assessed to determine their capacity to make decisions and if a DoLS application was required.

There was enough skilled and experienced staff on duty to meet people’s needs. A robust recruitment system had been undertaken, which helped the employer make safer recruitment decisions when employing new staff. At the beginning of their employment staff had received a structured induction into how the home operated, and their job role. They also had access to a varied training programme that met the needs of the people using the service.

People were provided with a choice of healthy food and drink, ensuring their nutritional needs were met. The people we spoke with said they were very happy with the meals provided and confirmed they were involved in choosing what they wanted to eat. We saw lunchtime on the day we visited was a relaxed and enjoyable experience for people who used the service.

People’s needs had been assessed before they went to stay at the home and we found they, and their relatives, had been involved in the planning of their care. However, their involvement was not clearly evidenced in the care files we checked. The care files we looked at reflected people’s needs and preferences so staff had clear guidance on how to care for them.

People had access to activities which provided regular in-house stimulation, as well as occasional trips out into the community. People told us they enjoyed the activities they took part in.

There was a system in place to tell people how to make a complaint and how it would be managed. We saw the complaints policy was easily available to people using and visiting the service. The people we spoke with told us they had no complaints, but said they would feel comfortable speaking to staff if they had any concerns. When concerns had been raised they had been investigated and resolved in a timely manner.

There were effective systems in place to monitor and improve the quality of the service provided. Where shortfalls had been identified by the management team in their audits, action had been taken to address them. However, we noted the general environment did require some attention in places.