St Marys Court is registered to provide accommodation, personal care and nursing for up to 90 people. There were 80 people living in the service when we inspected on 9 and 11 October 2018. The inspection was unannounced.

St Marys Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Marys Court accommodates people across three floors in four separate units. The service was purpose built, bright and airy and people had access to a range of outdoor spaces and gardens.

The needs of people using the service varied from residential, nursing and people living with dementia. A small number of people were receiving nursing care while they were waiting to return home following a hospital admission.

A registered manager was in place who had provided consistent leadership at the service for some years. 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 our last inspection of the service on 24 February 2016 we rated the service as good overall but outstanding in well led. At this inspection we found that they had maintained their rating. We again rated well led as outstanding because the quality of care that people received was continually assessed, reviewed and improved. The leadership of the service strived to create a service that offered outstanding care to people. We found elements of outstanding care in the other domains such as in staff training and in the activities provided. We identified some shortfalls which were largely in documentation but these were addressed by the registered manager during the course of the inspection.

The service had a robust recruitment process in place to ensure staff had the necessary skills and attributes to support people using the service. The service benefited from having an onsite trainer and all new members of staff completed an induction programme to develop their skills and knowledge. Ongoing training was provided which meant people received care from skilled staff who could meet their needs. Staff received supervision and annual appraisals to support them in their role and identify any learning needs and opportunities for professional development.

There were systems in place to ensure that risks associated with delivering care and with the environment were identified and managed. Incidents and accidents were logged and reviewed to identify learning. Medicines were well managed. Staff were clear about how to raise concerns and the safeguarding procedures.

People liked the food and the meals served looked nutritious and nicely presented. Staff had completed nutritional assessments for those people who were found to be at risk of malnutrition or a low fluid intake. This was clearly recorded in their care plans, and staff effectively monitored and recorded their food and fluid intake.

We saw that staff responded promptly to people’s changing health needs and referrals had been made to specialist healthcare professionals, including dieticians, optician and speech and language therapists, for additional advice and support.

Staff provided people with individualised care, which was centred on their needs and wishes. The care and support provided to people was based upon their preferences and were outlined in their care plan. People were supported to lead a full life and had access to a good range of activities.

People received care from staff who knew them and with whom they felt comfortable. Staff were thoughtful and patient when providing care and supported people to make choices about all aspects of their dai

This inspection took place on 24 February 2016 and was unannounced. There was a breach of the regulations in force at the time of the last inspection on 6, 7 and 8 January 2015. Therefore we followed up Regulation 17 Good governance. And found no on-going breach relating to the maintenance of accurate records.

St Marys Court is registered to provide accommodation, personal care and nursing for up to 90 people. At this inspection we found 75 people residing at the service. There is a passenger shaft lift to assist people to the upper and lower floor and the service is set in pleasant extensive grounds. The accommodation was purpose built, light and airy for people to enjoy. The outdoor spaces are developed with people at the service and made safe spaces with lawns, attractive raised beds, outdoors seating and wheelchair accessible. These add interest and provide a pleasant aspect.

The home had a registered manager in place. 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 at this service were keen to tell us of their positive experiences. People felt involved in the development of their care and support and were consulted on matters that affected them. Staff knew people well, but had up t date person centred care plans to guide them with risks mitigated where possible. People and their families told us that staff were caring, compassionate and acted with kindness. We observed a staff group that worked well with people and ensured peoples comfort with all their interactions. Staff were mindful of privacy and dignity and diversity of people and therefore treated people as individuals and respectfully.

The staff group truly understood and practiced the values of this organisation of Kindness, Comfort and Respect. The leadership was visible and led by example. Staff felt valued in their contribution. There were robust systems in place to recruit, induct, train and support staff to ensure there was a staff group who were effectively prepared to meet the needs of individuals in their care.

People were able to have a varied and interesting life that was supported by sufficient staff for them to access the community and a host of social activities that were widely advertised. People experienced the pleasure of good food that suited their needs, with people who needed a soft diet having food that was presented using moulds so that different foods were separate and looked like real food was intended to. People were supported to maintain good health and if their needs changed they were promptly referred and seen by medical practitioners. Qualified nurses had the skills to meet the nursing needs of people at this service. Medicines were managed so people got medicine as intended by the prescriber, but where possible people were supported to be independent and manage their own medicines.

The was a strong quality assurance system throughout the service that truly enabled a ‘floor to board’ approach with the provider seeking out new ways to understand the experience of people using the service and listening to what it was like to use the service. Managers were listening and were flexible in their thinking to take on suggestions made by staff, other professionals and people at the service. Managers and the provider responded to people if they made suggestions or made complaint to show how they had acted responsibly.

We spoke with four people who used the service. We looked at seven people's care records. Other records viewed included staff rosters, dependency scores and matrix for minimum staffing levels, health and safety checks, satisfaction questionnaires completed by the people who used the service and relatives, quality monitoring systems used by the manager and we toured most of the communal areas of the service. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service the registered manager greeted us and noted our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

Equipment within the service was maintained to ensure safety. This included hoists and shaft lifts. We saw servicing records which showed that health and safety matters in the service was regularly checked. This included regular fire safety checks, gas, electrical, water quality and temperatures. This meant that people were protected because the facilities were well maintained.

We saw the staff rota and dependency levels assessment which showed that the service assessed people's needs to ensure that there were sufficient numbers of staff to meet their needs. Four staff spoken with said there were sufficient numbers of staff on duty and that they were aware of how the dependency levels of people at the service was used to determine staff levels.

We examined an application made under the Mental Capacity Act (MCA) 2005 in relation to a Deprivation of Liberty Safeguards (DoLS). The application had been granted. This demonstrated that staff at the service were aware of the legislation and how to protect people and uphold their rights by appropriately using this legislation.

Is the service effective?

Care at St Mary’s Court was effective because we did not see higher than expected pressure sores or falls. Systems in place to audit medication and care plans made for effective organisation in the delivery of care.

People's care records showed that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. The records were regularly reviewed and updated which meant that staff were provided with up to date information about how people's needs were to be met.

Is the service caring?

We saw that the staff interacted with people living in the service in a caring, respectful and professional manner. We particularly found that staff on Ash were understanding of people’s needs and this was supported by the individualised care plans that related specifically to peoples support in relation to living with dementia. People told us that they liked the amount and types of activities on offer.

People using the service, their relatives and other professionals involved with St Mary’s Court completed satisfaction questionnaires. Where shortfalls or concerns were raised we did not see how that information was then used to improve the service.

Is the service responsive?

People using the service were provided with the opportunity to participate in activities which interested them. People's choices were taken in to account and listened to. This included regular trips out each week on the minibus.

The service had an effective complaints procedure in place. We examined records and saw that where people had raised concerns appropriate action had been taken to address concerns and where possible to the satisfaction of the complainant.

People's care records showed that where concerns about their wellbeing had been identified the staff had taken appropriate action to regularly review care plans. This included seeking support and guidance from health care professionals, including a doctor and district nurse. However not all people were aware of the content of their care plan and there was not a system or evidence in place to ask people their view on their care plan. The provider may like to note that there was no pain monitoring tool in place to ask people or for staff to observe pain type, levels and duration. Therefore staff currently could not respond efficiently to pain management where needed.

Is the service well-led?

The service worked well with other agencies and services such as health and social care professionals to make sure people received their care in a joined up way.

The service had quality assurance systems, audits and records seen by us that showed identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

We spoke with thirteen people who used the service, the registered manager, deputy manager and thirteen members of staff. We were also able to speak with the director of care as part of this inspection.

People told us that they were generally happy with the care that they received and they felt safe but they also told us that they thought there were not enough staff to support their needs at all times. We observed that staff provided care to people who used the service in a caring manner. We found that the number of staff on duty to meet people’s needs and the skill mix of staff was not always suitable or sufficient.

We found that whilst people said that they felt safe, their care records did not always support that they received safe or effective care that met their individual needs. We found that care plans were not always reflective of people’s needs. We also found that records relating to people’s care were not always accurate or fit for purpose. For example we saw two different examples of skin integrity risk assessments in people’s records. So it was not clear which one was to be referred to and followed.

We saw that the service had a management structure in place and that staff felt like they could approach senior management. Staff told us they were not always confident action would be taken on concerns raised.

This was a follow up inspection to determine if compliance had been reached on three compliance actions made on 26 and 27 July 2012 and 2 August 2012.

We found that significant progress had been made with regards to safeguarding, medication and staffing levels at the service. The service provided enough qualified, skilled and experienced staff to meet people’s needs.

The manager had introduced a falls prevention strategy that had reduced the number of falls experienced by people who used this service. This demonstrated that the manager was effectively managing this risk to people’s health and safety and had taken reasonable steps to prevent a reoccurrence.

On this occasion we did not speak with anyone who uses the service about the way their medicines are managed.

We observed that people who use this service were treated with respect and dignity. Staff knocked on people’s bedroom doors before entering. Staff closed doors and curtain blinds to ensure privacy before giving personal care. We observed that staff asked permission and listened to peoples preferences when giving personal care.

Two people we met told us that they were happy living at the service and that they were, “Alright”. We asked about the care support and health needs to one individual at the service and they told us, “Everything was fine”.

We did not receive any comments from people using the service during this follow up visit. However on our initial inspection visit to the home people with whom we spoke were generally satisfied with care and attention provided by staff. It was reported by the people using the service that if they required assistance staff would respond promptly.

This was confirmed by the visitors with whom we spoke on our initial visit who said that they felt involved with the care provided to their relative.

Most of the people who use this service have difficulty understanding and responding to verbal communication. During our visit we were able to hold a conversation with two people. Some others were able to make comments about specific issues, such as the meals, however most of the information about people's experiences of St Mary's Court was gathered through our observations, discussions with visitors, review of records and discussions with the manager and care staff.

People with whom we spoke confirmed that they were generally satisfied with care and attention provided by staff. It was reported by the people using the service that if they required assistance staff would respond promptly. This was confirmed by the visitors with whom we spoke who said that they felt involved with the care provided to their relative.

One person told us that they enjoyed the peace and quiet of their bedroom.

People with whom we spoke confirmed that the food provided was "good" and a choice of meals were offered by staff including meals prepared for people who found it difficult to chew and swallow. Visitors to the service were able to confirm this and said that they were generally happy with the meals provided to their relative and the assistance provided to other people by staff.

Visitors with whom we spoke told us that they felt able to approach staff with any concerns that they may have around the care provided to their relative and were confident that staff would address these whenever possible.

This was an unannounced inspection carried out on 6, 7 and 8 January 2015. At the last inspection in July 2014 we found that not everybody was receiving the care they needed and professional advice and support was not always being sought for people. There were no systems in place to develop solutions to reduce risk and protect people or drive improvement to the quality of the service being delivered. An action plan was received from the provider in October 2014 telling us of the actions they had taken to meet legal requirements. At this inspection we found that improvements had been made. Further improvement was required to ensure consistency and sustainability.

St Mary’s Court provides accommodation, personal care and nursing for up to 90 people. The service mainly provides care to people living with dementia; and/or people who need nursing and palliative care. There were a total of 71 people living in the service at the time of our inspection.

There are four units spread across three floors. Ash and Beech provided care for 23 and 10 people living with early onset dementia; Cedar provided nursing care for 30 people and Oak provided care for up to 27 older people living with advanced dementia.

The service has a registered manager. 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.

A lack of records in some areas including some relevant individual risk assessments, monitoring tools and care plans meant that people may not always be supported consistently and in the correct way. Staff did not always know about or understand how to use or check that equipment was being used safely.

There were robust systems in place to recruit and select new staff and ensure they were suitable for the role. Staff were not always deployed effectively across the service to ensure that at key times of the day people’s needs were responded to appropriately.

The provider had systems in place to manage safeguarding concerns and people’s medicines. Staff understood their responsibilities to report any concerns they may have.

People’s views about meals varied. Improvements were needed to ensure that people did not wait too long between each meal. Although snacks were available it was not clear how these were promoted or how people unable to communicate had their intake monitored. Records were also inconsistent so it was not possible to know in some cases what people had.

Plans were in place for staff training and professional development in areas specific to people’s healthcare needs including dementia. This enabled staff to meet their needs more effectively. However this was not yet fully implemented across the service. This led to some inconsistencies in staff practice. The management recognised needed to be improved and sustained.

The provider had recognised that the environment needed further development to meet the needs of people living with dementia and plans were in the initial stages to address this.

The provider had strengthened quality assurance and governance systems which enabled them to have a clear oversight of the service provided, work towards addressing the issues previously identified and drive improvement. However not all improvements had been fully implemented in some areas to show that they had taken effect and were being sustained.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.