St Mary's House

St Mary’s House is a care home without nursing care. The service provides care and support for up to 24 older people, some of whom are living with dementia. At the time of our inspection there were 21 people using the service.

We undertook this unannounced responsive assessment because we received information of concern about peoples at the care home. We reviewed all 14 quality statements related to the two key questions, Is the service safe and well-led? For those key questions not inspected, we used the ratings awarded at their last inspection to calculate the overall rating. This onsite assessment was conducted by a one inspector. For those key questions not inspected, we used the ratings awarded at their last inspection to calculate the overall rating.

People were at risk of avoidable harm because all windows observed at the inspection had not been fitted with widow restrictors, including people’s bedrooms. This meant people were at risk of falling from height. Following our inspection the provider confirmed they had installed window restrictors throughout the service in compliance with published guidance.

People were supported by skilled and knowledgeable staff who were vetted prior to recruitment and received on-going training and supervision throughout their careers. They understood their role in safeguarding people should they have any concerns. The management and staff team were well established and knew people well. People had individual risk assessments in place and staff followed guidance to keep people safe. People received their medicines safely and had timely access to health and social care professionals.

Staff were happy in their work and felt supported by the registered manager. The registered manager reviewed incidents and events to ensure lessons were learned and shared learning within the staff team to prevent reoccurrence. The provider worked in partnership with other organisations, including community, health and faith groups to meet people’s needs. The quality of service provision was monitored but audits did not always identify shortfalls. For example, health and safety checks did not reveal the absence of window restrictors or written records of important meetings.

The provider was in breach of the legal regulation relating to safe care and treatment and good governance. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.