We completed an unannounced inspection at St. Mary’s Nursing Home on 30 May 2018 and 31 May 2018. When we completed our previous inspection on 12 January 2017, we found a breach in Regulation 12, because the provider did not have safe medicine management systems in place. Improvements were also needed to ensure that people were treated with dignity, their choices were respected and the systems in place to manage the service were effective. The service was rated as Requires Improvement overall. We asked the provider to take action to make improvements to the standard of care provided. At this inspection we found that the provider continued to be in breach of Regulation 12 as sufficient improvements had not been made and we found a new breach in Regulation. You can see what action we told the provider to take at the back of the full version of the report.

St. Mary’s Nursing Home 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. Mary’s Nursing Home accommodates up to 58 people in one adapted building. There was a specific unit that provided care to people at the end of their life. At the time of the inspection there were 50 people using the service.

The service did not have a registered manager. The last manager de-registered with us on 9 April 2018. The provider had appointed a new manager in May 2018 who planned to register with us. 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.

We found that medicines were not always managed safely to protect people from potential harm.

Improvements were needed to ensure people received the least restrictive care and treatment to keep them safe in line with the Mental Capacity Act 2005.

Improvements were needed to ensure the systems in place to monitor the service people received were imbedded and sustained.

Risks to people’s health and wellbeing were managed and followed by staff who knew people well, which ensured people were supported safely.

There were enough suitability recruited and skilled staff to provide support to people. Staff had received training to ensure they had sufficient knowledge to carry out their role effectively.

People were protected from the risk of infection because the provider had policies and systems in place to control infection risks at the service.

The environment had been adapted in a way that promoted people’s safety.

People enjoyed the food provided and were supported with their nutritional needs. Action was taken to ensure people at high risk of malnutrition were supported effectively.

Advice was sought from health and social care professionals when people were unwell, which was followed by staff.

There were systems in place to ensure people received consistent care from staff within the service and also from staff from external agencies.

People received support from staff that were kind and compassionate. People’s dignity was respected and their right to privacy upheld.

People were supported with their communication needs and information was provided in a format people understood which meant that people were supported to make informed choices.

People received care that met their preferences. People’s past lives, cultural and diverse needs were assessed and considered to enable individualised care that met all aspects of people’s needs. People had opportunities to participate in social activities, interests and hobbies.

People were supported to have a comfortable, pain free death in line with their preferences because their wishes had been considered and planned.

This inspection took place on 12 January 2017 and was unannounced. At our previous inspection in April 2016 we found that the service was not meeting the required standards. Regulatory breaches were identified and the service was judged as inadequate and placed into special measures. We inspected the service again In September 2016 and found some improvements had been made in relation to ensuring people’s safety. However there were continuing breaches of the Regulations in relation to staffing and providing people with safe care and treatment. The service remained in special measures and was kept under review.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At this inspection we found improvements had been made in all areas of the service, none of the five key questions were rated as inadequate. Therefore the service will no longer be in special measures.

St Mary's Nursing Home provides support and care for up to 58 people. At the time of this inspection 54 people used the service.

The service does not have a registered manager. Recruitment for a registered manager was on-going; in the meantime an interim recovery manager was managing and leading the service. 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 medicines were not always managed administered stored or recorded safely. Improvements were needed to ensure a safe system of medication management was in place and was effective.

People were supported by some staff who were caring and compassionate. However, not all staff were as thoughtful or respectful as they should be when engaging with people.

Sufficient staff were available to keep people safe and meet people's care needs in a timely manner. Staff received induction, training and supervision they needed to ensure they felt able to provide care and support to people. Recruitment and vetting procedures were in place that ensured appropriate people were employed.

People were safeguarded from abuse and the risk of abuse as staff knew what constituted abuse and who to report it to.

People were supported with their care and support needs in a safe and consistent way through the effective use of risk assessments and care plans.

The principles of the MCA 2005 w

This inspection took place on 14 September 2016 and was unannounced. At our previous inspection in April 2016 we found that the service was not meeting the required standards. Regulatory breaches were identified and the service was judged as inadequate and placed into special measures. The breaches were in relation to the safe care and treatment of people, safeguarding people from abuse and improper treatment, staffing levels and governance arrangements.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At this inspection we found some improvements had been made in relation to safeguarding people from abuse and the governance arrangements. However there were continuing breaches of the Regulations in relation to staffing and providing people with safe care and treatment. The service will continue to be in special measures and will be kept under review.

St Mary’s Nursing Home provides support and care for up to 58 people. At the time of this inspection 56 people used the service.

The service had 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.

Staffing levels were insufficient to ensure people’s care and support needs were met in a timely and effective way.

People’s risks had been assessed, but improvements were needed to ensure these were monitored and managed to protect people from the risk of harm.

People's medicines were not always managed or administered in line with the prescribing instructions.

Mealtime choices were limited and did not always meet people’s personal preferences.

Staff were supported through training opportunities to require the knowledge and skills necessary to meet people’s individual care and support needs. Further training in specific topics were needed to ensure staff provided support in a consistent and reliable way.

The provider operated recruitment and vetting procedures that ensured appropriate people were employed. Regular checks were made to ensure staff continued to be of good character and able to work within their defined role.

People consented to their care and the provider followed the requirements of the Mental Capacity Act 2005 (MCA) where people lacked the capacity to make certain decisions about their care.

This inspection took place on 5 April 2016 and was unannounced. At our last inspection in June 2013 we found that the service was meeting the required standards in the areas we looked at.

St Mary’s Nursing Home provides support and care for up to 58 people. At the time of this inspection 57 people used the service.

The service had 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.

There was insufficient staff available to meet people's individual needs. People experienced delays when staff were needed to provide them with the care and support they required.

The provider did not have effective systems in place to assess, monitor and improve the quality of care.

The principles of the MCA were not consistently followed. People were at risk of unlawful deprivation as referrals for a DoLS assessment had not been made for some people who lacked capacity to consent to their care and treatment within the service.

Risks to people's health and wellbeing were identified and assessed but not always reviewed to ensure the action needed to mitigate the risks was recorded.

Staff did not always receive the training they needed to be able to support people in a safe way. This meant some people's specialist needs were not met safely or effectively.

People generally told us they enjoyed the food and were provided with suitable amounts of food and drink of their choice. Not all records for the purpose of monitoring people's fluid intake had been fully completed to ensure people's needs were fully met.

People had access to a range of health care professionals but follow up consultations were not always arranged.

Staff were kind and caring, however low staffing levels had a detrimental effect on meeting the care and support needs of all people.

There was a range of daily activities arranged for people to enjoy.

Staff were aware of the safeguarding procedures and knew where and to whom they could raise concerns.

The provider had a complaints procedure and people knew how and who to complain to.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

You can see what action we told the provider to

This was a unannounced scheduled inspection.The service did not know that we would be visiting.

At the time of our inspection 58 people were living in the home. We spoke with staff, visitors and people who used the service that were able to tell us about their experiences.

One person who used the service told us: "I moved here after a stay in hospital. I can't go home so I am planning to stay and so far it has been excellent. I am trying to get my room sorted so that I can have some things brought in from my home. The staff are all very good and friendly. The food is good and I can join in the activities when I wish to. I have no concerns".

Another person said: "St Mary's is home from home".

A visitor told us of their satisfaction with the care and support provided to their relative. They went on to say how much their relative had improved since they moved in.

Some people were unable to speak with us either because of frailty or personal preference. We spoke with staff about the care and support they provided. They gave a detailed account of the specific individual needs of people. We saw that staff treated people compassionately; offering discreet assistance to those who required it.

We saw that systems were in place to ensure that medication was administered in a safe way. Some improvements were needed for storing medication that required a cool environment.

We saw systems were in place for recruitment of staff and for effective record keeping.

During this inspection we saw that some people and/or their representatives were supported to make decisions and were involved in the planning of their care. We saw that where people found it difficult to make decisions, formal assessments were not in place to support them. Staff told us they get to know people well and so were able to support them with their care.

We spoke with staff about the care and support they provided each day, they offered an explanation of people's individual needs. We looked at a selection of care records to check the care being given to people. We saw some inconsistencies in the recording of people's care needs.

Some staff we spoke with told us about their understanding of safeguarding vulnerable adults and what they would do if they had any suspicions of wrong doings. Other staff were not too sure of the actions they would take. People told us they would speak with staff or a family member if they had any concerns about the care they received.

People who used the service told us the staff were very good and looked after them very well. We saw some staff supported people in a caring, compassionate way. Staff told us they were always very busy and additional staff would be beneficial.

We saw the service had a system for monitoring the quality of the service, some improvements would be beneficial.

Feedback comments received from other professionals about the service were generally very positive.

We visited the service and spoke with people using the service, their relatives and staff members. Feedback comments about the service included, “we are happy working here, and we get the support we need from our manager.” “We can choose what time we get up and go to bed, and if we don’t like the meal we can ask for something else.” ”The food is always of a good quality, and there’s plenty of it.” “I only have to ask to see my doctor and it’s done.” “The doctor visits twice weekly here.” “I had been at St Mary’s many times for respite, and liked it, so I decided to move in.” People told us they were happy with their individual bedrooms. Some people said they liked to spend most of their time there.

The previous key inspection report also told us that relatives and people using the service had been satisfied with the care they received.