This inspection took place on 5 and 7 April 2017. The first day of our inspection was unannounced. St Mary’s Care Home provides accommodation for people who have nursing and personal care needs. It is located in the centre of Chester-le-Street and close to local amenities.

Following the last inspection of St Mary’s Care Home on 18, 19 and 25 October 2016 we reported that the registered providers were in breach of the following:-

Regulation 9 Person Centred Care

Regulation 12 Safe care and treatment

Regulation 14 Nutrition and Hydration

Regulation 17 Good governance

We asked the provider to take action to make improvements and found during this inspection improvements had been made.

There was 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.

People were being given their medicines in a safe manner. Staff were patient and kin as they explained to people what their medicines were for. We found medicine records were up to date with no gaps. People’s topical medicines (creams applied to the skin) were being administered as prescribed.

Staff recruited to the service had undergone a number of checks to ensure they were suitable to work in a care home.

Regular checks were carried out on the building including fire checks, window restrictors and bed rails to make sure people were safe living in the home.

The service met the requirements of the Mental Capacity Act and the Deprivation of Liberty Safeguards. This meant staff had applied to the local authority to deprive people of their liberty and keep them safe.

The home had recently been decorated and there was some signage to help people orientate themselves around the building. We recommended the provider review the home in the light of recent research and guidance to develop a home where the needs of people living with dementia could be met.

We found staff were provided with support through induction, training and supervision, and saw since our last inspection staff had updated their e-learning.

The service had used the Herbert Protocol. This is a nationally recognised scheme where people who are at risk of going missing are registered so that their details can be immediately released if they go missing again.

Staff were aware of people’s histories and family members. They were able to engage people in conversation with humour. We found staff treated people with respect and dignity and personal care was carried out behind closed doors.

The service did not employ an activities coordinator. Staff had been advised to provide activities as well as carrying out their other duties. We saw staff were doing this however we found improvements could be made to coordinate activities, and encourage and support people in their individual hobbies and interests.

Since the last inspection people’s care plans had been brought up to date. We found they were accurate and reflected people’s individual needs. They included plans for people who had specific diagnosed conditions and additional information had been provided to staff about the conditions.

We found staff had improved their use of food and fluid charts and understood the importance of hydration. This meant people were no longer at risk of becoming dehydrated without staff taking actions.

The registered manager was able to tell us about the service and provide the information we needed to conduct the inspection.

People who used the service, relatives and staff were complementary about the effectiveness of the registered manager.

The registered manager had developed new initiatives in the home to ensure people received the care they needed and staff were competent in their role. This included a weekly review of

This inspection took place on 18, 19 and 25 October 2016 and was unannounced. This meant the staff and the registered provider did not know we would be visiting.

At our last inspection of St Mary’s Care Home in May 2016 we reported that the registered providers were in breach of the following:-

Regulation 9 Person Centred Care

Regulation 12 Safe care and treatment

Regulation 15 Premises

Regulation 17 Good governance

Regulation 18 Staffing

The overall rating for this service was 'Inadequate' and the service was placed in 'Special measures'. This is where services are kept under review by CQC and if immediate action has not been taken to propose to cancel the registered provider's registration of the service, the location will be inspected again within six months. The expectation is that registered providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following the last inspection in May and June 2016 the registered provider sent us an action plan and provided us with regular updates.

At this inspection we found there were some improvements. However we also found there were further continued regulatory breaches.

There was not registered manager in post when we visited the home and there had not been a registered manager there for the previous 18 months. 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. The service had appointed a new manager who had applied for their Disclosure and Barring Check for their CQC registration process.

Medication administration procedures and systems were not robust and did not protect people living at the home from risk associated with poor medicines management. We found that the administration of medicines at the home did not follow best practice guidance.

We found that checks to verify staff’s employment history were not carried out appropriately.

Chemicals being used at the home including professional type cleaners containing ingredients which were likely to cause injury if accidentally splashed or consumed did not have corresponding suitable information which could be used to promote safe storage and which could be followed in an emergency. Immediate steps were taken to improve safety once it was drawn to the attention of the provider.

We found improvements had been made where staff were now routinely recording people’s fluid intake. But where this was low, no actions were put in place to address the issue. This meant people continued to be at risk of dehydration. The registered provider had also failed to ensure that some people’s dietary requirements were accurately recorded in care files and this information was shared with catering staff. This posed significant risks to people’s health and well-being.

The registered provider was not doing all that was practicable to keep people safe because some unoccupied bedrooms which contained dangerous items could have caused injury to people living at the home, staff or visitors.

The manager had appointed two staff as ‘dignity champions’ for the home. However we saw an example where a person’s dignity was compromised.

We found examples where care plans gave incorrect or insufficient information to promote effective care or guide staff practice.

We found peoples care needs had not been reviewed when they moved back to the home from hospital where they had developed additional complex nursing and care needs.We found a number of examples where the service had not responded appropriately or in a timely manner to people’s urgent nursing care needs. This included where people had specific conditions, required end of life care or skin pressure care issues. This included an instance where

The inspection took place on 25, 26 May, 2 and 17 June 2016 and was unannounced. St Mary’s care home is located in the centre of Chester-le-Street and provides accommodation for people who require nursing or personal care. There were 30 people using the service on 25 May 2016 including people receiving respite care. On 2 June 27 people were using the service on 17 June 25 people were using the service.

At the last inspection on 1 and 2 September 2015, we rated this service as ‘Inadequate’. We served warning notices on the service and asked the registered provider to take action to make improvements, for example, on people’s topical medicines, staff supervision and documentation. The registered provider put in place an action plan to improve the service.

At the time of our inspection there was not 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. St Mary’s Care Home is owned by Carewell Healthcare Limited. One of the partners of Carewell Healthcare Limited employed a regional manager for other services provided by them. This regional manager had offered support to the manager of St Mary’s Care Home and was present during the inspection.

People who used the service and their relatives were complimentary about the staff. Staff displayed caring qualities towards people and treated them with kindness and respect.

We found the service met the requirements of the Mental Capacity Act 2005 (MCA) and had made applications to the appropriate authority regarding the Deprivation of Liberty Safeguards (DOLS).

The service had received a certificate from the initiative, “Focus on Undernutrition" in care homes. Staff confirmed to us they had completed the training. The initiative uses the Malnutrition Universal Screening Tool (MUST) which gives recommendations about people’s nutritional requirements if they are at risk of malnutrition. We found the home had not followed the requirements. Staff were not aware of what snacks were available for people who were diabetic.

The service had put in place fluid charts for people. We found staff had recorded the amount of fluid they were giving to people but not the amount they had actually drunk. The fluid amounts had been totalled; however there were no target fluid amounts in place. Staff therefore were unable to assess if people were at risk of dehydration. By 2 June 2016 the manager had begun to put in place target fluid levels. On 17 June 2016 we found information for staff had been put in people's files from Association of UK Dieticians regarding hydration including meeting the needs of older people.

We found Medication Administration Records for people’s prescribed topical medicines had not been completed. We also found there were no dates of opening on people’s topical medicines and topical medicines had not been destroyed in line with the manufacturer’s guidance. Following our visit on 26 June 2016 the manager had put in place a new system to manage people's topical records, however we found the system was not always adhered to.

The management team told us staff provided activities for people each afternoon. Staff told us they were not always available to do this as they were often called away to carry out other duties. During our inspection we saw staff had put a film on the television for people who were then left unsupervised. We found staff were not deployed to provide appropriate supervision of people.

Staff had received training in safeguarding and were able to tell us what actions to take if they had concerns about anyone using the service.

We looked at 10 people’s care records and found they contained personalised information to enable staff to provide ap

During our visit we found people were asked for their consent before they received any care or treatment and the provider acted in accordance with their wishes. We spoke with several people who used the service. They said staff respected their choices to make informed decisions and that they had control of their lives. One person told us, “I had been in hospital for some time and I was asked by the manager if I would like to come here. I think I made the right choice.”

We found care and treatment was planned and delivered in a way which ensured people’s safety and welfare. One person who lived at the home told us, “I’m happy, I’m properly looked after there’s nothing I can think of they’re not doing.” Another person said, “From getting up to going to bed they look after me well.”

We found effective measures were not in place to protect people from the risks of unsafe use and management of medicines.

We also found the provider had not taken steps to provide care in an environment that was adequately maintained.

The provider had taken steps to make sure people at the home were protected from staff who were unsuitable to work with vulnerable people by carrying out thorough background checks.

We found people who use the service were not protected against the risks of unsafe or inappropriate care because their records were not securely maintained.

When we visited the home we checked on improvements which were required following our previous inspection in October 2012. We also checked the homes laundry and other infection control and monitoring measures following an incident where the acting manager informed us the laundry was not able to be used which had led to a temporary build up of contaminated laundry at the home.

We did not record comments from people who were using the service or visitors as this was a follow up inspection.

When we visited we found there were effective systems in place to protect people from the risk and spread of infection because appropriate guidance had been followed.

We looked at the way equipment was used at the home. We found people were protected from risks of unsafe or unsuitable equipment because the provider had taken steps to make sure they were used and maintained properly.

We found the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and promote their health and wellbeing.

During our visit we spoke with several people who used the service and with their relatives. They said staff respected their privacy and dignity. They told us staff knocked on their bedroom doors before entering and were polite with them. One person said, “I really could not have any complaints at all, they are all so very good.” Another said, ”The staff are lovely - they look after me.”

People said their care was monitored by the provider and the manager to make sure it was meeting their needs. One person said, “We have meetings where they ask you about things like the food and activities.”

Another said,” I can speak to the nurses or the manager if there’s anything I’m worried about.”

This inspection tool place on 1 and 2 September 2015 and was focussed and unannounced. Following the inspection we asked the manager to provide us with further information and we collected this from the service on 11 September 2015.

At the last comprehensive inspection carried out in January 2015 we found there were regulatory breaches. The provider failed to ensure there was a registered manager at the home. The provider had not appropriately implemented the requirements of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) in respect of people living at the home. The provider had failed to ensure that care and welfare of service users was accurately planned.

In July 2015 concerns were raised with CQC by the local safeguarding team, the commissioning team and the Clinical Commissioning Group about the service given to people. The concerns were about the care given to people and the records kept by the service. The provider had an action plan in place to improve the service. We undertook this focused inspection to consider those concerns. This report covers our findings in relation to the concerns and any further issues we found during our focussed inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (location's name) on our website at www.cqc.org.uk

We carried out the unannounced focused inspection of this service on 1 and 2 September 2015. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting.

St Marys provides accommodation, personal and nursing care for up to 54 older people. The home is set in its own gardens in a residential area near to Chester le Street town centre, public transport routes and local community facilities.

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. At the time of our inspection a manager was employed by the service and had submitted an application to register to the Care Quality Commission.

People told us they felt safe in the home. Their relatives also thought people were safe in the home.

The provider did not have in place arrangements to ensure people received their topical medicines safely.

Accidents and incidents were recorded in the home but the manager was unable to find the records for July 2015.

We observed staff in the dining room supporting people to eat and a member of staff sitting feeding a person at a pace that was unhurried.

Notifications were given to kitchen staff about people’s dietary needs; we found these were not always clear.

Suitable arrangements were not in place to manage and monitor people’s hydration needs. We found volunteers gave out drinks to people and staff who collected the cups recorded the person’s consumption by the cup nearest to the person.

We found staff were carrying out health checks for which they had not been trained. Staff had not been supported to carry out their duties through training and supervision. The provider had devised a plan to train staff.

The provider had brought into the service a manager to oversee the improvement of people’s care planning. However at the time of inspection people had not given their permission to involve their relatives.

We found plans which were in place for people were not always being carried out. This meant people were not always receiving person centred care.

People told us they knew how to make a complaint and we found the provider had in place a complaints procedure. We saw the manager had followed this procedure to investigate a complaint.

We found the provider had failed to keep accurate and contemporaneous records about people’s care. Records were not stored in a secure manner and some records were not made available to us.

We saw the provider had carried out a relatives survey in July 2015, the provider had recorded out of 48 questionnaires sent out one survey had been returned by a relative. During the same month 47 questionnaires were sent out to staff and five staff responded. These responses indicated staff did not feel supported by the manager and the staff did not see a manager whilst working night shifts

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.