St Mary's

We assessed 6 quality statements in the safe key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good.

The assessment of these areas indicated areas of concern since the last inspection.

We found a breach of the legal regulation in relation to good governance. The learning culture was not always robust. Themes and trends were not always identified through the provider’s systems currently in place. Staff meetings took place. However, outstanding concerns were not discussed. Although regional manager meetings took place there was no record about what was discussed during these meetings. This meant we could not be assured areas of concern were identified and managed.

We also found a breach of the legal regulation in relation to need for consent. Clear and complete records were not always available to show how people's capacity was assessed. Assessment of people's capacity to make decisions where restrictions had been applied were not always completed. Where people may have regained capacity, decisions made in their best interests were not always reviewed in a timely way.

We also found a breach of the legal regulation in relation to safe care and treatment. Not all risks for people were identified and recorded in relation to their care and support needs to ensure their safety and wellbeing. Systems were not always in place to ensure people's assessed needs were care planned. This meant people were at risk of receiving inappropriate care and support.

Systems and processes were not in place to ensure the safe management of medicines. Where people were prescribed 'as required' or variable dose medicines, clear guidance was not always recorded to help make sure staff administered an appropriate dose of people's medicines when needed.

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.

We assessed 1 quality statement in the caring key question and found evidence of good practice. The score for this area has been combined with scores based on the rating from the last inspection, which was good.

People told us they had choice. Comments included, “I laid in this morning, but that was my choice”, “I can get up when I want. If I missed breakfast, they would still find me something”, “I get up when I want and go to bed when I want.” Staff told us they prompted people to make choices about day-to-day decisions, such as where and how they wanted to spend their time and what they wanted to wear. However, it was not always clear if the person using the service understood the questions asked because some people were living with dementia and staff were not directed to check understanding.

We assessed 1 quality statement in the responsive key question and found evidence of poor practice. The score for this area has been combined with scores based on the rating from the last inspection, which was good.

There was a lack of robust ways to gather feedback to drive improvement from the services. The provider completed surveys for people who had just moved into the service. However, general feedback surveys were issued each month, but none had been returned. There had been no review to identify why surveys were not returned to take action to develop alternative ways of gathering feedback. The registered manager told us ‘resident/ relative’ meetings had just started. However, the most recently planned meeting has not taken place as the registered manager told us ‘the day had gotten away’ and no relatives turned up. There was no information on display to show when the next meeting was and advertise this to people and their relatives.

We have made a recommendation about how the provider ensures people’s views are sought and acted upon.