Archived: St Mary's Nursing Home

Updated 30 April 2021

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 is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We received information of concern about infection control and prevention measures at this service. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 16 March 2021 and was announced.

Updated 30 April 2021

This inspection took place on the 09 January 2018 and was unannounced. St Mary's Nursing Home is a 'care home'. People in care homes receive accommodation and nursing, or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. St Mary's Nursing accommodates up to 20 people. There were 14 people living at the home at the time of our inspection.

At the last comprehensive inspection in December 2016 we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because of issues in the way people’s medicines had been managed. Following that inspection the provider wrote to us to tell us the action they would take to address our concerns. At this inspection we found that the issues we had identified had been addressed, in line with the provider’s action plan.

The service had a registered manager in post. 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 2008 and associated Regulations about how the service is run.

At this inspection we found that people were protected from the risk of abuse because staff were aware of the different types of abuse that could occur, the signs to look for, and the process for reporting and escalating any allegations, should they need to do so. There had been no allegations of abuse involving people at the service in the time since our last inspection.

People told us there were sufficient staff on duty during each shift to ensure their needs were safely met. The provider followed safe recruitment practices. Risks to people had been assessed and management plans put in place to ensure any identified risks were safely managed. Medicines were safely stored and appropriately recorded. People confirmed they were supported to take their medicines as prescribed. People were protected from the risk of infection because staff were aware of the provider’s infection control procedures.

The registered manager reviewed the details of any accidents that occurred at the service to help reduce the risk of repeat occurrence. People’s needs were assessed, and care and treatment delivered in line with nationally recognised guidance and standards. Staff received an induction when they started work at the service and were supported in their roles through a range of training in areas considered mandatory by the provider, and through regular supervision and an annual appraisal of their performance.

People told us they were happy with the décor at the service. They were supported to maintain a balance diet and spoke positively about the food on offer at the service. They also had access to a range of healthcare services when needed and staff worked to ensure people received co-ordinated care across different service types in support of their health.

Staff were aware of the need to seek consent from people when offering them support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff were aware of, and worked in line with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) where people lacked capacity to make specific decisions for themselves.

Staff treated people with kindness and consideration. They respected people’s privacy and treated them dignity. People were involved in decisions about their care and treatment. They told us that the care they received met their individual needs and preferences. The provider offered a range of activities for people to take part in, in support of their need for stimulation. People were also supported to maintain the relationships that were important to them and relatives confirmed they were welcome to visit the service whenever they wanted.

The provider had a complaints policy and procedure in place which provided guidance on how to raise concerns. People and relatives expressed confidence that any issues they raised would be addressed by the registered manager. They told us that the service was well managed and that staff worked well as a team. The registered manager confirmed that the staff worked with the GP and local hospice team to ensure people received appropriate and dignified support at the end of their lives, although none of the people living at the service required this at the time of our inspection.

The registered manager held regular staff meetings to discuss the running of the service and to remind staff of good practice. The service worked in partnership with other agencies including local authority commissioners, and the local Clinical Commissioning Group (CCG), in support of people’s needs. People’s views on the service were sought through regular discussion and an annual survey, and they told us they were happy with the service they received. Staff worked well as a team in an open culture that was welcoming and compassionate. The provider had systems in place to monitor the quality and safety of the service, and improvements were made were issues were identified through the monitoring processes.