Background to this inspection
Updated
27 August 2021
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
This inspection was carried out by two inspectors and included a member of the CQC medicines team.
Service and service type
St Mary’s Haven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service since the last inspection.
The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.
We used all of this information to plan our inspection.
During the inspection-
We met and spent some time with people living at the service. We spoke with four members of staff. We also spoke with the registered manager, operations manager and two visiting healthcare professionals.
We reviewed a range of records. This included four people’s care records. We checked 11 people’s medicines records and looked at arrangements for administering, storing and managing medicines. A variety of records relating to the management of the service, including finance and health records were reviewed.
After the inspection
We continued to seek clarification from the registered manager to validate evidence found.
Updated
27 August 2021
About the service
St Mary’s Haven is a residential care home providing personal care. The service can support up to 46 people. At the time of this inspection there were 31 people living in the service. Some of these people living in St Mary’s Haven are living with dementia.
People’s experience of using this service and what we found
People told us they were happy with the care they received and people said they felt safe living there. One person said; “Staff are good and come when I need them." Another said; “The care, devotion and empathy given by staff was outstanding.” One professional said; “I go to a lot of homes and this is a nice one.” People looked happy and comfortable with staff supporting them. Staff were caring and spent time chatting with people as they moved around the service.
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.
People were supported by staff who completed an induction, training and were supervised. Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction and activities with staff. Staff knew how to keep people safe from harm.
The environment was safe, with upgrades ongoing and people had access to equipment where needed. A recommendation, about pictorial signage to help support people who needed orientation to their surroundings, made at the last inspection is in the process of being actioned.
Improvements had been made to the way medicines were managed, and people received their medicines safely in the way prescribed for them. We made a recommendation about the way medicines were stored to make sure they were always kept at the correct temperature.
Staff received appropriate training and support to enable them to carry out their role safely, including fire safety and mental health training.
People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.
Records of people's care were individualised and reflected each person’s needs and preferences. Risks were identified, and staff had guidance to help them support people to reduce the risk of avoidable harm. People’s communication needs were identified, and where they wanted, people had end of life wishes explored and recorded.
People were encouraged by staff to eat a well-balanced diet and make healthy eating choices. Special diets were catered for.
People were supported by a service that was well managed. Records were accessible and up to date. The management and staff knew people well and worked together to help ensure people received a good service.
Staff told us the registered manager of the service was approachable and listened when any concerns or ideas were raised. One staff member commented that the registered manager was ‘very supportive’.
People and their families were provided with information about how to make a complaint and details of the complaint’s procedure were displayed at 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 29 February 2020) 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.
Why we inspected
We carried out an unannounced inspection of this service on 16 January 2020. 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 they would have complied with Regulation 11, Need for consent, Regulation 12, Safe care and treatment, Regulation 17, Good governance and Regulation 18, Staffing.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-led which contain those requirements.
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Requires improvement to Good. 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 Haven on our website at www.cqc.org.uk.
Follow up
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.