Background to this inspection
Updated
6 July 2019
The inspection:
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the registered provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
Inspection team:
The inspection was carried out by one Inspector, one ‘Expert by Experience’ and a ‘Specialist Advisor’. An ‘Expert by Experience’ is a person who has personal experience of using or caring for someone who uses this type of care service. A ‘Specialist Advisor’ is a person who has professional experience and knowledge of the care which is being provided.
Service and service type:
St Mary’s is a ‘care home’. People in care homes receive accommodation and nursing or personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service had a manager registered with CQC. This means that they and the registered provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection:
The inspection was unannounced.
What we did:
Before the inspection we reviewed the information we held about the service. This included any statutory notifications sent to us by the registered provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send to us by law. We also contacted local commissioners of the service to gain their views. We used the information the provider sent us in the ‘provider information return’. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all this information to formulate a ‘planning tool’; this helped us to identify key areas we needed to focus on during the inspection.
During the inspection:
We spoke with the registered manager, 10 members of staff, two external professionals, one kitchen assistant, 19 people who were living at St Mary’s and seven relatives who were visiting at the time of the inspection. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We looked at care records of four people receiving support, four staff recruitment files, medication records, and other records and documentation relating to the management and quality monitoring of the service.
In addition, a Short Observational Framework for Inspection (SOFI) tool was used. SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
Updated
6 July 2019
About the service:
St Mary's Continuing Care is a purpose built ‘care home’ and is located in the residential area of Collins Green, Burtonwood in Warrington; the home is divided into four separate units and provides nursing and personal care for up to 63 people with acquired brain injury, early onset dementia, mental health support needs and older people living with dementia. At the time of the inspection 63 people were living at St Mary’s.
People’s experience of using this service and what we found
People received high-quality, person-centred care. The quality and safety of care people received was monitored, assessed and (where needed) improved upon.
Medicine management procedures were safely in place. We did note that some areas of practice did not comply with the providers medication administration policy. We have made a recommendation regarding this.
People’s level of risk was assessed and managed from the outset. Support measures were put in place, areas of risk were monitored, and regular reviews meant that people were receiving the most up to date and relevant care.
Care records were person-centred and provided staff with information in relation to people’s likes, dislikes, wishes and preferences. Staff told us they were able to develop positive relationships with the people they supported.
Safeguarding procedures were in place and staff told us how and when they would raise their concerns. People who lived at St Mary’s told us they felt safe.
Staffing levels were analysed and reviewed in relation to the dependency needs of people who were living at St Mary’s. Staff had also been safely recruited.
People were supported to have maximum choice and control of their lives and staff supported people in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
We observed kind, considerate and compassionate interactions between staff and people receiving support. People and relatives told us that the care provided was tailored around individual support needs.
People were supported to participate in activities that were engaging, stimulating and were having a positive impact on their health and well-being.
The provider had an up to date complaints policy in place. Complaints were regularly monitored and reviewed and responded to in line with company policy.
The registered manager maintained a good level of oversight in relation to ‘governance’ and quality assurance processes. Processes and systems ensured that the quality and safety of care was routinely being assessed and reviewed.
St Mary’s offered a warm, friendly and inviting atmosphere, each of the units were tailored to the support needs of the people living there; although we did recognise one unit required some attention.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection:
The last rating for this service was ‘good’. (Report published 7 December 2016). At this inspection, the rating remained ‘good’.
Why we inspected
This was a planned inspection based on previous ratings.
Follow up:
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.