St Mary's

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 1 quality statement in the effective key question and found areas of concern. The score for this area has been combined with scores based on the rating from the last inspection, which was Requires Improvement. We found a breach of the legal regulation in relation to safe care and treatment. Robust systems were not in place to monitor and make sure people's needs were consistently met. For example, monitoring charts had not been used effectively to make sure people regularly changed their position to reduce the risk of them developing skin damage in line with their care plan. Fluid charts did not always align with required amounts. There was no evidence these records were being reviewed and monitored. Systems were not always in place to ensure there were appropriate care plans for people's assessed needs. This meant people were at risk of receiving inappropriate care and support. It was unclear whether people were receiving a nutritious and balanced diet. The daily notes did not consistently detail what people had to eat throughout the day. The registered manager told us they were aware the daily record keeping needed to be improved. Following our assessment the registered manager told us they had arranged for senior care staff to complete medicines audits in the future and the registered manager will check these. We also found a breach of the legal regulation in relation to good governance. Care plan audits were taking place. 100 care plans had been reviewed as part of ‘resident of the day’. However, no changes or actions were recorded on any of them. The auditing system did not identify the concerns we found.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

People told us they were unsure if they had a care plan and confirmed resident meetings did not take place. Comments included, “No I don’t think I have a care plan. I’m not sure. I can’t remember being asked about one”, “I don’t think I have a care plan. No one’s ever told me about one”, “I don’t know anything about a care plan”, “I don’t think I have a care plan. What is it exactly?”, “No, we don’t have resident meetings”, “We don’t have any resident meetings or anything” and “I can’t remember having any type of meetings.”

The registered manager told us people and their relatives were involved in the development and review of their care plans.

Robust systems were not in place to monitor and make sure people's needs were consistently met. For example, monitoring charts had not been used effectively to make sure people regularly changed their position to reduce the risk of them developing skin damage in line with their care plan. Some people were recorded as needing 2 hourly repositioning, however monitoring documentation had gaps of 3-4 hours. Fluid charts did not always align with required amounts. For example, 1 person was recorded as requiring 1878ml a day, their monitoring records showed days where they had received 120ml. There was no evidence these records were being reviewed and monitored. Systems were not always in place to ensure there were appropriate care plans for people's assessed needs. This meant people were at risk of receiving inappropriate care and support. It was unclear whether people were receiving a nutritious and balanced diet. The daily notes did not consistently detail what people had to eat throughout the day.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.