We carried out an unannounced inspection on 29 July 2016.

The service provides care and support to people with a variety of care needs including those living with dementia, physical disabilities, mental health needs and chronic health conditions. On the day of our inspection, there were 28 people being supported by the service.

During our inspection in July 2015, we had found the provider needed to make improvements in some areas including the décor of the lounge, responsiveness of staff to people’s needs and the quality of the care records. We found improvements had been made during this inspection.

There was no registered manager in post. However, a new manager had started the process to register with the Care Quality Commission. 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.

The provider had effective systems to keep people safe and staff had been trained on how to safeguard people. There were individual risk assessments that gave guidance to staff on how risks to people could be minimised. People’s medicines had been managed safely and administered in a timely manner by trained staff. The provider had effective recruitment processes in place and there was sufficient numbers of staff to support people safely.

Staff had received effective training, support and supervision that enabled them to provide appropriate care to people who used the service. The manager and staff understood their roles and responsibilities in ensuring that people consented to their care and treatment, and that this was provided in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). People had nutritious food and they were supported to have enough to eat and drink. They had access to other health and social care services when required in order to maintain their health and wellbeing.

Staff were kind and caring towards people they supported. They treated people with respect and supported them to maintain their independence as much as possible. Staff had developed caring relationships with people they supported and people valued their support.

People’s needs had been assessed and they had care plans that took account of their individual needs, preferences and choices. Care plans had been reviewed regularly or when people’s needs had changed to ensure that they were up to date. Staff were responsive to people’s changing needs and where required, they sought appropriate support from other health care professionals. A variety of activities had been planned and provided to occupy people within the home, and trips organised to visit places of interest for people who used the service. The provider had a formal process for handling complaints and concerns. The provider’s area manager had also provided their contact details so that people or relatives could contact them if they had concerns that had not been resolved by the manager.

The provider had effective systems to assess and monitor the quality of the service. They encouraged feedback from people, relatives and staff, and acted on the comments received to continually improve the service. The area manager had provided effective support to the new manager. Everyone we spoke with had been complimentary about the improvements made since the new manager was in post.

We carried out an unannounced inspection on 20 July 2015.

The service provided care and treatment to adults, some of whom may be living with a variety of needs including chronic health conditions, physical disabilities and dementia. At the time of the inspection, 26 people were being supported by the service.

The service has a registered manager. 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.

There were risk assessments in place that gave guidance to staff on how risks to people could be minimised. There were systems in place to safeguard people from harm.

The provider had effective recruitment processes in place and there was sufficient, skilled staff to provide the care people required.

Staff received supervision and support, and had been trained to meet people’s individual needs. They understood their roles and responsibilities to seek people’s consent prior to care being provided.

People were supported in a timely manner, by caring and respectful staff. They were also supported to access other health and social care services when required.

People’s needs had been assessed, and care plans took account of people’s individual needs, preferences, and choices. However, people sitting on their wheelchairs for long periods increased the risk of them developing pressure area damage to the skin.

The provider had a formal process for handling complaints and concerns which in the majority of cases, were resolved to people’s satisfaction.

The provider encouraged feedback from people and acted on the comments received to improve the quality of the service.

The provider had effective quality monitoring processes in place. However, some of the care records were not always up to date.

When we visited St Mary’s Nursing Home on the 9 June 2014, we gathered evidence to help us answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well- led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found where people were at risk of poor fluid and food intake and tissue damage risk assessments had been completed. These had been regularly reviewed to make sure information was current and reflected people’s needs.

We saw that people’s medicines had been administered in line with current best practice guidelines. Appropriate arrangements were in place for the storage, recording and disposal of controlled medicines to ensure that medicines were handled safely.

We found that a new maintenance system had been introduced. This was to ensure when bedrooms became vacant they were re-painted before a new person took up occupancy.

Is the service effective?

We found that the care plans took people’s wishes and preferences into account and contained information about people’s life histories. This enabled staff to provide care that was sensitive and responsive to people’s individual needs.

People received effective care from staff who had the knowledge and skills to carry out their roles and responsibilities. This was because staff were provided with effective support, training, supervision and appraisal.

We found that people’s bedrooms were single occupancy and the shared areas of the premises consisted of living and dining areas. Bathrooms were accessible to people who used a wheelchair and those with other mobility issues. This meant that people’s privacy and dignity were promoted and they had access to safe and suitable premises.

Is the service caring?

Staff were observed speaking to people in a kind and respectful manner and provided them with reassurance to ensure their well-being was promoted.

We found that arrangements had been put in place for people and their relatives to express their views and be involved in making decisions about their care, treatment and support. This was because people and their relatives had been written to and provided with the opportunity to meet with staff to review their care needs.

Is the service responsive?

We found that people’s assessed needs had been regularly reviewed. Where people were at risk of pressure damage, they were provided with special equipment to minimise the risk of damage. This meant that people received care that was responsive to their needs.

People had access to a range of activities such as arts and crafts, chair exercises, word games, gardening and tea parties. Where people chose not to participate in group activities, one to one activities were provided. This meant that the risk of social isolation was minimised.

We found that the home listened and learnt from complaints made by people and their relatives. For example, we saw evidence that feedback obtained from the outcome of a complaint had been used to improve the quality of the care provided.

Is the service well led?

Staff said that they felt supported by the registered manager. We found where concerns in staff performances had been identified these had been dealt with using the organisation’s formal processes to support them and drive improvements. This was to ensure that care was provided safely and effectively.

We found the home had a quality assurance system in place. This was used to make improvements to the quality of the care provided and to respond to issues in an open and transparent manner.

We inspected St Mary's Nursing Centre on 8 October 2013 to review improvements made following the enforcement action we took against the provider in August 2013. Prior to our inspection we received concerns relating to the cleanliness of the home, the maintenance of equipment and insufficient staffing levels. We also assessed each of these areas as part of our inspection.

When we revisited St Mary’s Nursing Centre on 8 October 2013 we spoke with six people using the service, two visiting relatives and six staff members who worked at the service.

We looked at the care records for eight people using the service. We found that improvements had been made to the care planning process and records were well maintained and up to date.

We looked at the systems in place for cleanliness and infection control. We found that overall, there were effective systems in place to reduce the risk and spread of infection.

We observed that equipment was available in sufficient quantities to ensure the safety of people using the service. Records showed that equipment had been maintained as necessary and was suitable for its purpose.

We noted that there were numerous staff vacancies at the home. These vacancies were being covered by the use of agency staff to ensure sufficient staff were on duty throughout the day. The provider had recruited five new staff and was continuing to recruit more staff.

We visited St Mary’s Nursing Centre on 14 August 2013 to review improvements made within the home following the previous inspection on 15 April 2013. During this inspection we found a different environment which was more welcoming, relaxed and friendly. We observed positive engagement and interactions between staff and people using the service.

We spoke with seven of the 33 people using the service who told us they were happy with the care and support provided. One person said: “All the carers are very nice. I have no complaints.”

We looked at the care records for 13 people's using the service. We found that overall improvements had been made to the care planning process and records were generally well maintained and up to date. However four files lacked some essential information about people which meant some people may not receive the care and treatment they needed.

Staff were more positive about working in the home and they told us team working had improved and the atmosphere was more relaxed.

We saw evidence that the number of staff on duty was sufficient to meet the needs of people currently living at St Mary’s Care Centre. However the 20 rehabilitation beds on the upper floor were empty and there were six vacant beds on the lower floor. If numbers increased, the staffing levels would need to be assessed against people’ needs to ensure their needs could be met.

We found that the provider had reviewed and improved its complaints process and procedures.

At our previous inspection visit on 15 April 2013 we identified major failings related to cleanliness and infection control. During this inspection we found the environment to be clean, tidy and free from odours.

We spoke with five of the 39 people using the service and two visiting relatives. We also spoke with four staff members currently working at the service. People we spoke with said they had noticed a difference to the cleanliness of the home. All the people we spoke with confirmed that the problem of the recent mouse infestation appeared to have been resolved. One person said "I haven't seen any mice for a long time."

Records demonstrated that the home had systems in place to ensure that the appropriate standards of cleanliness and hygiene were maintained and to prevent, detect and control the spread of infection.

We spoke with 15 people out of the 45 people currently living at the home and five relatives of people using the service. In addition we were able to talk with three visiting professionals and five staff members. Of the five family members we spoke with, they all told us they were unhappy with the level of attention their family members were receiving, due to what they described as the lack of staff on duty.

Records we looked at were incomplete and not always updated as people needs had changed.

Systems in place were not robust enough to ensure that a quality service was provided to the people living at this home.

Records we looked at were not stored securely and not always up to date. As a result care was not being delivered at the level required.

We spoke with nine people in total using this service who told us their choices were respected and that staff were very helpful and respectful.

They said they were offered choices at meal times, choices about when they got up or went to bed, and also told us they were involved in decisions about their care.

Two relatives said the care in the home was very good and they were confident that their relatives were looked after well. They said “the staff are lovely and they care for people very well.”

People receiving care on the rehabilitation unit knew about the programme of support in place to support them. We were told that staff took their time when assisting people but were often rushed. They said that staff were very busy in the mornings but things were usually a lot quieter after breakfast.

One person told us they were happy with the support they had received and this had made it possible for them to go home.

We carried out a visit to St Mary’s nursing centre on 22 August 2011 and 14 September 2011 to check compliance. During our visits we spoke to a number of people using the service and some visitors. We also took the opportunity to observe how the staff interacted and provided care to enable us to determine what it was like for people living at St Mary’s. In addition we considered information that had been shared with us by other agencies including reports from Luton compliance team and Luton safeguarding team.

We received positive comments from everyone we spoke to about the way their care was delivered. During our second visit we spoke with one person whose care had been under investigation because of a medication error. He told us that he and his wife had been fully informed of the incident and were confident that the staff took the appropriate action when the error was noted. However we did not see any documentation that showed that people using the service, or a family member, had been consulted about their care plans by being asked to sign to confirm their agreement with them.

We asked people about the care they received. Some people were able to tell us about this. One person who had been at the home for six weeks said that sometimes the days dragged, but they were complimentary about the care they had received and the improvement to their mobility. Another person said, “you can tick all the boxes, it has been like a holiday for me”.

A relative told us that they believed that care had improved recently and said it was apparent that ‘staff were trying’.

On 22 August 2011 we were aware that breakfast was served very late. When discussing this one person said, “I would like my breakfast earlier as it is not long until lunchtime and I need room for that”.

We received information following a review of the service undertaken by Luton Borough Council and Luton PCT on 24 and 25 January 2011 and we made a visit to the service 01 March 2011.

The residents of the rehabilitation unit told us that they were treated well by staff, given choices and encouraged to make decisions about their care. One resident told us about a plan to make a visit to their home prior to their eventual discharge; they told us, 'They have to make sure I can get in and out of bed and do some simple tasks.'

Everyone we saw presented as clean and well dressed. However, there was evidence that a number of residents had been exposed to harm and placed at risk whilst in the home; others were too poorly to fully participate in their rehabilitation.

Those residents on the rehabilitation unit during our visit were able to tell us about the plan for their care but people on the nursing unit were less well informed. Before the visit, we had been provided with documentary evidence that showed that the care planning processes were fragmented and were poorly co-ordinated. There was confusion and a lack of clarity regarding roles and responsibilities to update care plans and records. This has exposed people to the risk of receiving inappropriate care and has led to others suffering harm.

Regardless of the area of the home that accommodated them, all the people that we spoke with told us that the food was good and that they had plenty to eat. One person said, 'It seems no sooner is one meal over than it is time for the next, it is no wonder I have put on the weight I lost in hospital.'

During our visit on 31 May 2011 we looked in detail at the files of four people who had been admitted to St Mary’s for rehabilitation since the voluntary embargo to admissions had been lifted by the council at the end of April 2011. We spoke with these people and also two other people using the service and observed the care provided to them.

The manager had told us that she was confident that all the people she assessed for rehabilitation whilst in hospital had agreed that they wanted to undertake the rehabilitation programme and that they had agreed their goals for the period of their stay. However when we spoke to people few of them felt that they had been involved in their move to St Mary's. One person who had been in the Luton and Dunstable Hospital said, “I had no option but to come here really, I can’t really remember being asked". They went on to say that staff treated them well. A person who had transferred from hospital to St Mary’s rehabilitation unit was able to tell us about the programme they were undertaking. This person said, “I know if I want to go home I have to do more walking and eat better, but sometimes I don’t feel like it”. Another person told us that they spent a lot of time on their own and had to wait for attention when they rang for help.

During lunchtime one person told us they were not really very hungry when their lunch arrived as it had only been three hours since they had breakfast. Another person said, “I like the food here, there is always something I fancy on the menu”.

We did not hear how the improvements made since our visit 01 March 2011 had impacted on people using the service as everyone we spoke with had been admitted since April 27 2011 when admissions to the home had recommenced.