We inspected this service on 15 January 2018. The inspection was unannounced.

St Marys is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single packages under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Marys accommodates up to 23 older people including people living with dementia. On the day of our inspection 14 people were living permanently at the service and three people were receiving respite care.

The service had a registered manager 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During the home’s previous inspection in January 2017 we identified one breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was in relation to Regulation 17 Good Governance. Systems in place to check on quality and safety were not as effective as they should have been. Following this inspection the registered provider was required to send us an action plan to inform us of the action they would take to make the required improvements.

During this inspection we checked to see whether improvements had been made, we found the breach in regulation had been met and all areas of the service had improved resulting in positive outcomes for people.

People were protected from potential abuse and avoidable harm because staff were aware of their role and responsibilities and had received safeguarding training that informed their practice. Risks in relation to people's needs including the environment were assessed, planned for and monitored.

Action had been taken to improve the internal environment, this included some refurbishment work, repairs and replacement of furnishings.

There were sufficient staff employed and deployed to support people. Safe staff recruitment practice was in place and followed. People received their prescribed medicines safely and these were managed appropriately. Protocols in place to advise staff of medicines prescribed to be taken as and when required were not consistently detailed.

People lived in a clean, hygienic service and there was a prevention and control of infections policy and procedure guidance to support staff. Staff supported people effectively during periods of anxiety that affected their mood and behaviour. Accidents and incidents were reported, monitored and reviewed to consider the action required to reduce further reoccurrence.

People were supported effectively by staff that knew and understood their individual needs. Staff received an appropriate induction, ongoing training and opportunities to discuss their work, training and development needs. New staff had not always received training in a timely manner but action was taken to immediately address this.

People's dietary needs had been assessed and planned for and they received a choice of meals and drinks. Systems were in place to share relevant information with other organisations to ensure people's needs were known and understood. People were supported to access healthcare services and their health needs had been assessed and were monitored. Staff worked well with external health care professionals in managing people’s health needs and outcomes.

People had 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. The principles of the Mental Capacity Act (2005) were followed when decisions were made about people's care. Deprivation of Liberty Safeguards were in place for some people where required.

People were supported by staff who demonstrated a good understan

We carried out an unannounced inspection of the service on 12 January 2017.

St Marys is a care home with 23 places for older people and people living with dementia. On the day of our inspection there were 11 people living permanently at the service and four people receiving short term care.

St Marys is required to have 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 the time of the inspection there was a registered manager in post.

At our last inspection of the service on 25 January 2016 we identified the provider was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had not ensured staff had received appropriate training, development and support.

After the inspection the provider sent us an action plan to tell us of the action they would take to make the required improvements. At this inspection we found the breach in this regulation had been met. Staff received an appropriate induction when they commenced their employment. The frequency of staff supervision and appraisal meetings for staff to discuss their work and development had increased. Staff received appropriate opportunities to complete training and update their knowledge and skills.

Some concerns were identified with the environment, this included safety concerns relating to dining chairs, radiators and maintenance to windows.

Staff had received training in adult safeguarding therefore were aware of how to protect people from harm. Risks associated to people’s needs had been assessed and planned for. However, those people in receipt of short term care had no risk plans in place to instruct staff of what their needs were. Accidents and incidents were recorded, monitored and analysed for themes and patterns and action was taken to reduce further reoccurrence.

There were sufficient staff on duty on the day of our inspection to meet the needs of people at the service. However, there were no clear systems used to review people’s dependency needs to ensure sufficient staff were available at all times. Staff were recruited through safe recruitment processes.

Following an infection control audit by the local clinic commissioning group, improvements were being made to the cleanliness of the service and the measures required in the prevention of infections. Some issues were identified with the management of medicines. This involved not having clear information about medicines used as and when required, and how people liked to take their medicines. The audits in place had failed to identify some minor discrepancies with the stock of medicines.

People’s rights were protected under the Mental Capacity Act 2005. Staff were aware of the principles of this legislation and correct action had been taken when people lacked mental capacity to consent to their care.

People received a choice of what to eat and drink and these met people’s needs and preferences. People were supported appropriately with their healthcare needs and the service worked well with external healthcare professionals.

On the whole staff were caring, kind and compassionate and had a good approach when supporting people. People were involved in opportunities to discuss and review the care and support they received. Information about independent advocacy services was available should people have required this support.

People told us that they found the activities limited. Care plans to support staff to know how to meet people’s needs in the main were informative and were reviewed regularly. However, there were no care plans in place for people in receipt of short term care. Information about the provider’s complain

We carried out an unannounced inspection of the service on 25 January 2016.

St Marys is a care home with 23 places for older people and people living with dementia. On the day of our inspection 13 people were living at the service.

St Marys is required to have 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 the time of the inspection there was a registered manager in post.

At our last inspection of the service on 10 June 2015 we identified the provider was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There were not effective systems to assess monitor and improve the quality and safety of the service. After the inspection the provider sent us an action plan to tell us of the action they would take to make the required improvements. At this inspection we found the breach in this regulation had been met.

A new breach of Regulation was identified, this was Regulation 18 of the Health and Social Care Act 2008 Regulations 2014: Staffing. The provider had not ensured staff had received appropriate training, development and support. You can see what action we told the provider to take at the back of the full version of the report.

People told us that they felt staff, and the environment supported them to remain safe. Whilst staff knew what their responsibilities were in protecting people from abuse, not all staff had received appropriate training. Risks had been assessed and plans were in place to advise staff of the actions required to manage and reduce known risks. Appropriate action had been taken when accidents or incidents had occurred.

People said that they received their medicines safely. Medicines were administered, managed, stored, ordered and disposed of appropriately and in accordance with good practice guidance. Staff had received training and observational competency assessments to ensure they managed medicines safely.

There were sufficient staff available and deployed appropriately, to meet people’s individual needs and safety. People told us that staff responded in a timely manner to requests for assistance, and that staff had time to spend with them. Safe staff recruitment practices were in place.

The principles of Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards were understood by staff. Examples of assessments of people’s mental capacity to consent to their care and treatment and best interest decisions were in place and we found MCA legislation had been adhered to with one exception. Whilst the GP had authorised the use of covert medicine a MCA assessment had not been completed. Covert is the term used when medicines are administered in a disguised way.

People told us that they received sufficient to eat and drink. This included a choice of meals and their individual preferences and needs were known and understood by staff. Staff supported people where required with their eating and drinking needs.

People’s healthcare needs were known by staff and monitored. When people’s health needs changed, timely and appropriate referrals were made to healthcare professionals for advice and support. People told us that they were supported to maintain their health by having access to routine health checks and outpatient appointments that monitored their health.

People spoke positively and were complimentary about the approach of staff. They described staff as kind, caring and compassionate. People said they were involved in discussions and decisions about how they received their care and support as fully as they wanted. Staff were knowledgeable about people’s preferences, routines and what were important to them. Peo

We carried out an unannounced inspection of the service on the 10 June 2015.

St Marys is a care home with 23 places for older people and people living with dementia. On the day of our inspection 12 people were using the service.

St Marys is required to have 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 the time of the inspection there was not a registered manager in post. We were already aware of this and was monitoring the situation. An assistant manager was in place that had three days of management hours a week. In addition they was also the cook for two days a week.

During our last inspection on 8 July 2014 we asked the provider to take action to make improvements to protect people living at the home. The provider was not meeting six regulations of the Health and Social Care Act 2008. We served two warning notices due to concerns in relation to infection control and the systems in place to assess and monitor the quality of service.

Additional concerns were found with consent to care and treatment, care and welfare for people, safety and suitability of the premises and supporting staff.

Following that inspection the provider sent us an action plan to tell us the improvements they were going to make. Prior to this inspection we visited the service to follow up on the warning notice served in relation to infection control and found the provider had taken the required action. At this inspection we found that four of the remaining breaches had been met but improvements were still required. Some action had been taken to meet the requirements of the warning notice we served about the systems in place to assess and monitor the quality of service. However, we still had concerns that further improvements were required.

People and their relatives told us they were satisfied with the care and support provided and all felt their needs were being met. They had developed good relationships with the staff team and told us they were treated with kindness and respect and felt safe using the service. Relatives we spoke with confirmed this. Some people raised concerns about the lack of opportunities to pursue interests and hobbies.

We saw that people were well supported by a staff team that understood their individual needs. However, improvements were required to ensure people were consistently treated with dignity and respect. Whilst our observations showed at times staff had limited time to spend with people, the provider assessed and monitored people’s dependency needs for changes.

The assistant manager understood the requirements of the Deprivation of Liberty Safeguards 2008. We found examples of where these procedures had been appropriately followed. Staff understood the Mental Capacity Act 2005 and people were supported to give consent to their care and treatment. Some shortfalls we found on the day of our inspection were addressed immediately by the provider.

Staff recruitment procedures were robust and ensured that appropriate checks were carried out before staff started work. Staff received an induction and had received additional training to refresh and update their knowledge. Staff felt well supported by the assistant manager who provided formal opportunities for staff to discuss and review their practice and learning needs.

We found that the medicines policy and procedures needed some improvements. Staff were aware of safeguarding procedures to ensure that any allegations of abuse were reported and referred to the appropriate authority.

Improvements had been made in the planning and delivery of people’s care and people had received the care and support they required. People’s needs were assessed and plans were in place to meet those needs. Staff understood what people’s individual needs were and acted accordingly. Risks to people’s health and well-being were identified and plans were in place to manage those risks. People were supported to access healthcare professionals whenever they needed to. People’s nutritional and dietary requirements had been assessed people received sufficient to eat and drink.

The assistant manager had worked at improving the quality of service provided. However, we were concerned about the leadership of the service. The continued absence of a registered manager impacted on the continued improvements required. After our inspection the provider sent us written confirmation of immediate action they had taken to address these concerns.

Staff were clear about the values and aims of the service and were committed to continual improvement. New quality and safety assurance systems had been introduced. However, these required further improvements to fully protect people. The provider was in the process of gathering the views and opinions of people who used the service and monitoring the quality of service provided. We had not always been notified of all relevant incidents.

We found the service was in breach of one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We had issued a warning notice to the provider following our last inspection on 8 July 2014. We did this inspection to check that improvements had been made.

We spoke with a person using the service and a relative and asked if they were satisfied with the standard of cleanliness in the home. One person said, “Yes it is fine. My room is cleaned daily and I’ve had some new bedding recently.” Another person told us, “It looks better now they have done some decorating.”

We carried out a tour of the building and saw that improvements had been made to the standard of cleanliness. New carpets had been laid in the downstairs area and some new mattresses and bedding had been supplied.

Prior to our visit we reviewed information we had received from the provider. During the visit we spoke with three people who used the service and asked them for their views. We also spoke with three staff members and looked at some of the records held in the service including the care plans of three people. We observed the support people who used the service received from staff and carried out a tour of the building.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

This is a summary of what we found-

Is the service safe?

People were cared for in an environment that was not clean or hygienic. For example, there was an odour of urine in three bedrooms and one person's mattress protector had torn. Staff had not received recent training in infection control.

We spoke with three people who were using the service and asked about their medication. The people we spoke with told us that they had no concerns about the way in which their medication was handled. We observed that appropriate procedures were followed by staff whilst administering medication.

Staff were carrying out regular checks of safety systems such as the fire alarm and bedroom call bells. In addition, regular fire drills were carried out by staff. Hot water temperatures in one area of the building were recorded as being well below the recommended temperature. The building was generally tired in appearance and the external areas were shabby.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had not been trained to understand when an application should be made, or how to submit one.

Is the service effective?

Care plans were in the process of being rewritten at the point of our inspection. The records we looked at contained a varying quality of information, some sections were detailed and we observed the care being provided as detailed in the care plan. However, other sections contained information that was out of date or incorrect.

Where people lacked the capacity to provide consent, the provider had not always acted in accordance with the law.

Staff were not being appropriately supported in relation to their duties. There were significant gaps in the provision of training. We checked four staff files, only one of these members of staff had received a supervision meeting in 2014.

Is the service caring?

We spoke with three people who were using the service and asked if they were happy with the care and support they received. One person said, “Yes it is marvellous here.” Another person said, “I haven’t been here for too long but I am very happy so far.”

We spent periods of time observing the care and support that was provided to people throughout our inspection. We observed that staff were kind and caring in the way they supported people.

Is the service responsive?

One person became distressed at various points throughout the inspection. Staff responded by offering this person reassurance and the person then became more settled.

However we also observed occasions where staff did not or were unable to provide the support people required. For example over the lunch period, several people required staff support or prompting to eat their meals. This support was not provided consistently when people required it and some of those meals were not fully eaten.

Is the service well-led?

The provider did not have an effective system in place to assess and monitor the quality of the service being provided. There was no evidence available to demonstrate that the provider visited the home. One audit was being carried out in relation to medication, however this did not cover all relevant areas of medication management. No other audits were being carried out. The systems in place to assess risks to people’s health and safety, and take action when a risk was identified, were not effective.

We spoke with three people who used the service who were able to tell us they were happy and felt supported by the staff at St Marys.

We found that proper steps had not been taken to assess and plan the care that was being delivered, which meant that care did not meet the individual needs of people who used the service.

We found that some medicines were not handled in accordance with safe practice and infection control procedures did not protect people who used the service.

The management arrangements in place had not ensured that the home was well run and the provider did not ensure the quality of the care being delivered met minimum standards.

This visit was carried out to check the provider had complied with the actions we had set following our last visit. In order to do this we inspected some records and discussed these with senior staff.

We found the provider had complied with the actions we set. However, we found that there was a risk that people who used the service could experience poor care, which could have an impact on their health, safety or welfare because there were not enough staff to provide a consistent level of care and there was not always suitable equipment to manage their needs safely.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not all able to tell us their experiences.

We spoke with seven people who used the service and two visitors. We looked at the care plans and daily records for five people. We examined the recent accident records and the daily care and support records. We also looked at the written comments the home had received from relatives of service users who had been living at the home during the previous three months.

People using the service told us that they were happy with the care and support they were receiving and felt their health care needs were being supported by the staff at the home and local primary medical services. One person told us, "I am happy here, the staff are really nice to me, always helpful and caring."

Two visitors, who were relatives and advocates of people who used the service, told us they had no concerns about the service provided. One relative told us, " My relative is properly looked after, I visit regularly and I see that they always take good care of her."

We observed people to have their personal care needs met and staff delivered care in a way that ensured people’s safety and welfare.

Compliment cards and letters received by the manager since February 2012 reflected that the staff were considered to be dedicated, helped people feel secure and provided loving care to people who used the service during the last days of life.

We spoke with two people who were able to comment on their involvement with their care and treatment at the home and both said they were able to make decisions about their care, were allowed privacy and independence and access to the community. Comments included,

“I have no complaints at all, and the staff meet my needs well.”

“I feel safe here, and I have no worries at all.”

“The food is great and the staff are really nice.”

“I love my room, it’s kept clean and tidy, I have all my personal possessions around me and it’s nice and warm.”