St Marys

During this assessment, we identified shortfalls in the way the service was managed. We found the provider was in breach of the legal regulation relating to safe care and treatment and good governance due to concerns identified with employment records, training records, recruitment files, daily notes, overall management oversight, and people’s environment which placed people at risk of harm.

Staff knew people well, and we observed warm, genuine interactions that reflected a strong, ‘family like’ culture within the home. There was a dog in the care home which was a comforting companion for people and their visiting relatives. Relatives consistently told us they had confidence in the staff team and felt their loved ones were well cared for. The registered manager was visible, approachable, and committed to improving people’s experiences. People benefitted from kind support, meaningful engagement, and stable relationships with long-standing staff.

However, during this assessment we found areas where improvement was needed to ensure the service consistently provided safe and well led care. Daily notes and other care records were not always completed in a timely way, which meant important information about people’s wellbeing and care was not always available to guide staff decision making. This increased the risk that early changes or concerns in people’s health and support needs could be missed.
We also identified environmental safety concerns that had not been recognised or addressed through existing checks. These included unsecured tall furniture, unrestricted windows, overloaded electrical extension leads, a bed stored unsafely on the landing, and hot water temperatures that remained above safe limits despite being identified in a 2023 risk assessment as being an issue. These concerns showed gaps in environmental monitoring and increased the risk of avoidable harm.Governance systems were not always effective. Audits were completed but lacked the depth needed to identify the concerns we found during the assessment. Shortfalls in recruitment records, training oversight and quality assurance processes meant leaders did not always have effective oversight of the service. This resulted in missed opportunities to identify risk, drive improvement, and ensure systems were reliable.

Despite these concerns, the registered manager and provider were responsive to feedback and took prompt action when concerns were raised. We have asked the provider for an action plan in response to the concerns found at this assessment.