The inspection took place on 4 and 5 September 2018 and was unannounced on the first day. At the last inspection on 1 and 2 August 2017, we rated the service Requires Improvement. We found breaches in regulations which related to information in care plans, consent, medicines management and overall governance of the service. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe, Effective, Responsive and Well-led to at least good. Whilst we found some improvements in all areas at this inspection, there were concerns in the way risk was managed, care plans were recorded and maintaining accurate records. At this inspection, we have rated the service as Requires Improvement again.

Providers should be aiming to achieve and sustain a rating of 'Good' or 'Outstanding'. Good care is the minimum that people receiving services should expect and deserve to receive and we found systems in place to ensure improvements were made and sustained were not fully effective. As this is the second time in a row the service has been rated Requires Improvement, we will meet with the provider to discuss their action plan for improvements.

There was no registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. A new manager had been employed and they were to start the registration process with CQC.

St Marys 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 Marys Nursing Home is a single storey, purpose-built home, situated in its own grounds in a residential area of west Hull. The service can support up to 48 people who may have a range of physical health needs; some people may be living with dementia. There are 40 bedrooms, four of which are for shared occupancy. There is a large communal room which incorporates a dining area and seating areas for watching television or quiet time. There are plenty of bathrooms, shower rooms and toilets within easy reach of bedrooms. At the time of the inspection, there were 48 people using the service.

There were inconsistencies with people’s care plans. Some people had care plans, which contained good information and guidance for staff in how to meet their needs; these had improved since the last inspection. However, other people’s care plans lacked important information which meant there was the possibility of care being overlooked. Three people did not have care plans to manage their anxious behaviour, which could at times be challenging to themselves and other people.

Risk was not always managed safely. Most people had risk assessments for specific areas such as moving and handling and nutritional concerns. However, some areas of risk had not been identified and assessed properly, which could place people at harm of injury.

We found some areas of recording required improvement such as daily recording of the care given to people and monitoring charts when people were at risk regarding food and fluid intake.

The above three concerns were breaches of Regulations 9, 12 and 17 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

Overall governance had improved, shortfalls identified and action planned, however, the provider needed to follow through with these plans to make sure they were completed. We have given a recommendation about this. The new manager in post was aware of the shortfalls and wa

The inspection took place on 1 and 2 August 2017 and was unannounced on the first day. At the time of the inspection, there were 42 people using the service.

St Marys Nursing Home is a single storey, purpose-built home, situated in its own extensive grounds in a residential area of west Hull. The service can support up to 48 people who may have a range of physical health needs. There are 40 bedrooms; some have en-suite facilities and some are for shared occupancy. There is a large communal room divided into distinct areas for dining, watching television, relaxing quietly and enjoying a chat and a coffee with friends and family. There are plenty of bathrooms, shower rooms and toilets within easy reach of bedrooms. There is a large enclosed, landscaped garden and patio, which provides a secure area for people to enjoy the outdoor space.

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.

During the inspection, we found some concerns regarding the management of medicines. People had not always received their medicines as prescribed due to stock control or administration practices.

There was an inconsistency in the implementation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). This had led to some people potentially being deprived of their liberty unlawfully as staff had not recognised they met the criteria for a DoLS. Not everyone who lacked capacity had best interest meetings to record how decisions were made on their behalf. However, staff had a good understanding of the need to gain consent from people prior to carrying out care tasks.

People had assessments of their needs completed and care plans developed but these were not always thorough and information was missing from them. This had the potential for important care to be overlooked and also care to be delivered which wasn’t in line with people’s preferences.

Although we recognised there was a quality monitoring system that had just been started, which consisted of an audit timetable, surveys and meetings to gain people’s views, this had not been embedded into practice yet. This had resulted in shortfalls being missed when audits and checks were completed and when some issues were identified, these had not been addressed in a timely way. We could see this was a result of changes implemented since the new provider had taken over the service and their priority had been focussed on upgrading the environment. The refurbishment plan was well underway and some areas were looking very nice.

You can see what action we have asked the provider to take in response to concerns about medicines management, consent, care planning and quality monitoring at the back of the report.

We found staff had received training in how to safeguard people from the risk of harm and abuse. They knew what to do if they had concerns and how to report them. Staff had completed risk assessments for people, which helped to identify areas of concern and how to help minimise them.

We found staff were recruited safely and there were sufficient staff on duty to meet people’s needs. Some people told us response times to call bells could be improved. This was to be checked out by the registered manager.

People who used the service and their relatives were complimentary about staff approach. They said staff were kind and caring and respected people’s privacy and dignity.

People’s nutritional needs were met and menus provided a range of meals and alternatives over a four-week period. There were some mixed comments from people who used the service about the variety of meals; the registered manager told us they would complete a survey to check o

We found that complaints documentation had been reviewed, updated and available in the reception for people to use. A suggestion box had also been placed in the entrance area which enabled people to make an anonymous complaint should they wished to do so.

People who used the service commented, “Staff are wonderful and I cannot find any fault with them.” “Nothing is too much trouble for them and staff always treat me with dignity and respect.”

A visiting relative commented, “Staff always inform us regarding hospital appointments for our family member We are generally told after care is delivered and we trust the staff implicitly to provide care first and tell us later.”

We spoke with four members of staff and they were able to describe the procedures in place to report any safeguarding incidents they may witness or become aware of.

Staff were provided with opportunity to undertake further professional development in the form of recognised qualifications appropriate to their role, for example National Vocational Qualifications in health and social care.

Although people were aware they could make a complaint there was no evidence that complaints were monitored or recorded which ensured comments were listened to and acted on effectively.

We looked at care records and found them to be maintained on a daily basis and legible. Nursing notes were legible and accurate relevant to a person’s level of care needs.

We spoke with four people who were receiving care at the home. They had all been resident for a period of a few months and shared their experiences with us.

All agreed that the quality of care was high, the staff attentive and “always there” when needed. One person told us that their health issues that were not related to their confinement were also cared for with regular visits from healthcare professionals. Another person commented favourably about the activities available, including the choices of a small day room or the large residents’ lounge. All felt the provider asked for their opinions on a range of subjects from food to activities as well as personal preferences such as whether they wanted more privacy or to be encouraged to participate in activities. All those spoken with were aware of the following day’s event to be held in the main lounge.

All those spoken with agreed that the food was of a high quality, including the variety of dishes. One person said they felt the menu included some foods they had never had before and liked the experience whilst another person stated they were more comfortable with a traditional dish.

People told us they were happy with their care, that staff respected their privacy and dignity, and that they were well looked after. They saw their GP and other health professionals when needed.

People said they enjoyed their meals, had plenty to eat and drink and said that they had completed a survey about the food just recently.

People told us about the range of decisions and choices they could make in relation to day to day living. Generally this was fine but they said they missed the activities that no longer took place and could easily get bored.

People knew how to complain and said they would have no hesitation in talking to the manager about any concerns.

Everyone spoken with said the home was clean and warm. Comments were, "it’s like a new pin".

St Mary's Nursing Home is a single storey, purpose-built home, situated in its own extensive grounds in a residential area of west Hull. It is registered for accommodation for persons who require nursing or personal care, treatment of disease, disorder or injury and diagnostic and screening procedures. The home can accommodate 48 people including 12 people who need rehabilitation following a stroke. People’s stay in the stroke unit varies according to their rehabilitation needs and rate of improvement. The stroke service is commissioned by the local Clinical Commissioning Group [CCG].

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission [CQC] 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 last full inspection took place on 19 June 2013 and the registered provider was issued with a compliance action regarding the management of complaints. We completed a follow up inspection on 2 October 2013 and found the registered provider was compliant in this area.

We undertook this current unannounced inspection on the 10 and 11 June 2015.

We found there were sufficient staff on duty to meet people’s assessed needs. Staff had been recruited safely and received induction, training and supervision to ensure they were competent to look after people. The registered manager had an open-door policy which encouraged staff to raise issues.

We found people in the main unit and the stroke unit had their health care needs assessed and met. They had access to a range of health and social care professionals for treatment, advice and support. Risk assessments were completed and measures put in place to minimise risk.

Care plans for people in the main unit were person-centred and provided staff with guidance about how to meet their needs. Care plans for people in the stroke unit could be more person-centred. There was a lack of integrated care notes for nursing and therapy staff and an inadequate handover of information from the Acute Trust when people were admitted from hospital with a stroke. This meant staff at the service had to rely on verbal handovers and may not have all relevant written information to hand. We have made a recommendation about this which can be seen in the Responsive section of this report.

Medicines were managed well. People received their medicines as prescribed.

People’s nutritional needs were assessed and met. There were varied menus with alternatives and the meals provided during the inspection looked well-presented and hot. Those people with special dietary needs were catered for and dieticians and speech and language therapists visited specific people for nutritional advice and treatment.

We found staff supported people to make their own choices about aspects of their lives. Staff followed best practice in relation to the Mental Capacity Act 2005 when people were assessed as lacking capacity to make decisions; these were made in their best interest by people involved in their care. We found people were treated with dignity and respect. The staff approach was observed throughout the day to be kind and caring.

There were some activities provided to people to ensure they were stimulated and to help them participate in things that interested them. Therapy staff assessed people who used the stroke unit and assisted them, where possible, to regain skills and a level of independence.

There was a quality monitoring system in place that ensured checks were made and people were asked for their views about the service provided. Complaints were listened to and investigated. These monitoring systems enabled learning to take place and quality to improve.

We found people who used the service lived in a safe and clean environment. Equipment was maintained and repairs completed quickly.