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CQC Response

CQC Response

St Mary’s is registered with CQC (Care Quality Commission). CQC is responsible for registering and inspecting care and nursing homes amongst other establishments.

Rating: Requires improvement

Safe Good

Effective Requires improvement

Caring Good

Responsive Good

Well-led Requires improvement

Our response

25 June 2019

St Mary’s Nursing Home Response to CQC Report May 2019

The team at St Mary’s Nursing Home thought it might be useful for our residents, their families, friends and visiting professionals to know our response to our latest inspection report and the actions we plan to take to further improve care at St Mary’s.

We recognise that we need to continually update practices and improve services. However we are very disappointed that CQC felt we needed improvement in two domains and have again seemed, to us, to focus their inspection on paperwork.

We received a draft inspection report and were able to complete a factual accuracy form to highlight any changes that we felt were relevant and we want to share with you a few of the points we raised. On the day of the inspection we were told that our last inspection was over two and half years ago and that due to other priorities locally our inspection had been pushed back as they had had no intelligence or concerns.

In the draft report it stated that CQC will ‘continue to monitor intelligence’. Intelligence/concerns usually come from the following sources: CQC notifications, Local Authorities, Commissioners, Police, Paramedics or any other professionals either involved directly or indirectly with the Nursing Home and its Service Users. We asked CQC to remove the word ‘continue’ as they had stated they had not received any so why would they ‘continue’ to monitor and not just ‘monitor’. They said ‘No’ and that quote ‘This is standard text inserted into reports and is reflective of CQC continual monitoring of services’

As part of the inspection process we are asked by CQC to complete a Provider Information Return which we did prior to this inspection and previously in October 2015. We informed CQC that page 5 of the report was inaccurate as they had stated ‘we require providers to send this at least once annually ‘and asked them to amend this as it was incorrect. They said ‘No’ and that quote ‘This is standard text inserted into all reports and is reflective of CQC requesting Provider Information Return (PIRs). This wording has not impact on the judgement made’

We do recognise that documentation may have let us down at the time of inspection. We are pleased to note, however, that feedback in the report from relatives and residents is extremely positive;
We feel that the report does not reflect all the good work that we do and we are a good home and the inspection only provides a snapshot of us.

Report Findings and Our Actions

CQC wanted us to improve some aspects of our SAFETY, such as:

Unlocked medication fridge
Since the inspection we have developed a daily lock check form that will be signed after every visit to the fridge to ensure compliance. A fridge audit will be carried out monthly. An unlocked fridge is not accepted practice and we wish to reassure everyone that at no time was anyone living in the home at risk due to the fridge being unlocked in the 1st floor lounge. If you have any concerns please do not hesitate in speaking to myself or the nurse on duty.

Staff availability
The CQC raised concerns about the night time staffing levels on the 1st floor regarding the care needs not being met due to them identifying incomplete records. We believe that incomplete record keeping is a theme across all shifts and does not mean that the care is not being delivered due to reduced staffing levels. We undertook the following to reassure ourselves that the home is safely staffed at all times.

We did identify that when a new resident, with complex needs, is admitted to the home we would assess prior to admission whether an additional support worker would be necessary.

We are aware that one member of staff during the inspection said an extra carer was needed at night on the 1st floor and we feel that this has impacted upon the final report. To clarify: on the day of the inspection there were 24 Service users living on the 1st floor being cared for at night by a nurse and a support worker with a nurse and two support workers on the ground floor that are able to offer support during the night if needed.
Since the inspection there have been several night visits and we have sent out questionnaires to all night staff including agency staff. We are very pleased with the response. We sent out 11 questionnaires and have received 100% back. Of those sent out one has worked on the ground floor only and the other 10 have worked either 1st floor only or both floors.
Only one of the 11 sent out says the 1st floor does not have enough staff at night and one other says varies and does not give a definitive yes or no to whether the staffing level at night is sufficient.
After analysing the results of the questionnaires we believe an update for training on moving and handling is required for the two negative results.

We use a dependency tool to underpin our decisions regarding our staffing levels. The nightshift is a waking shift and there are no nursing duties such as a full medication round. The two night staff support service users with repositioning, bathroom needs and offer drinks and snacks as required.

CQC have stated that Regulations were met however they have graded EFFECTIVE as Requires Improvement and want us to improve:
We asked how we Require Improvement if the regulation was met. We were told us it is possible to be rated Requires Improvement in a domain and not have a breach of the regulations. This means that whilst there was no legal breach, some improvements were required before a rating of Good can be given.

Pre admission assessments
At present our pre admission assessment tool is in line with the domains carried out with in the care prescriptions we receive from CHC and hospitals so they complement each other when gathering information. We are however looking at updating and adding additional information gathering guidelines to ensure a more through and robust pre admission assessment.
Pre-admission assessments are generally carried out in an acute setting such as the hospital and therefore they are carried out with Doctors and Nursing staff and we are looking at whether we can firstly meet the person’s medical and physical needs within the home. Whilst it is important that we have an overview of a person’s holistic care needs it may be difficult to obtain this information in a hospital setting. It is important to us and we will continue to talk with our relatives and the people that are important to our service users to gain this information on admission.

Oral care
We recognise that oral care is not assessed and this has been added to our pre admission assessment and specifically mentioned in our personal care plans. Since the inspection we have developed a daily oral care sheet and are up dating our care plans to be more detailed.

Our main dining rooms are in the centre of the home where the kitchenettes and the lift to access both floors is situated. This has become the focal point for most of our service users.
We are extremely disappointed that our lunchtime did not go as smoothly as we would have expected. It is a busy environment and we are actively encouraging our staff to utilise other areas within the home.
We were saddened to think that one person living with dementia may have missed his meal because he left the table and was taken back to the dining room by a support worker and sat at a different table. We now have a designated member of staff to coordinate the dining room on the ground floor dementia unit.
The inspector informed us of this incident and in hindsight we should have questioned as to why nothing was said to the staff to prompt them to get him a lunch at that time.

Garden access
It is important for our service users to access the outdoors and we have always accompanied someone when they would like to go outside. We have agreed that it is important for people to access the outdoors and since the inspection we have now unlocked our doors that access the gardens for our service users to go out freely and independently as they wish. We will continue to ensure their safety as a priority.

CQC have graded us as Requires Improvement in Well Led and state that we have breached Regulation 17 of the Health and Social Care Act 2008. This means that “Quality assurance systems are in place but may be inconsistently applied”.

CQC highlighted that records were not always completed and that more checks and audits were needed. We are updating our audits from the feedback given on the day of our inspection for example, medication administration.

CQC informed us that we had to have a rotational chart for application of Controlled Drugs (CD drugs). Since the inspection we checked for CQC online guidance and it states ‘Staff should record the application of a patch and include the specific location, for example front, right, chest. This could be recorded on a body map. This is important so other staff can check that the patch is still in place’.
We have had regular visits from Medicines Optimisation Team and since our inspection we contacted them for clarification. Their advice was that rotational charts would be good practice although they do not have the resource at present. Although we had always identified this on our medication administration charts (MARS), we have sourced a rotational body map and with the support from our local medicines team implemented it in practice.

Improvements to our monitoring records for diet intake of our residents. We have improved our paperwork so that our nurses or seniors sign after every meal time for residents who need their intake monitoring. The forms are now audited on each shift to ensure support staff have completed them.

We accept that our monthly audit and visual checks were not adequate after one mattress setting on the day of inspection was identified as incorrect. Since the inspection we have implemented a twice daily check sheet and will continue with the monthly audits. We wish to reassure you that our residents skin condition particularly those that stay in bed is monitored numerous times a day and we have an excellent record of no pressure sores.


We are determined that next time we are inspected by CQC we will be able to show them all the evidence required to demonstrate that St Mary’s can not only deliver the highest quality care as standard practice but we can complete our paperwork consistently.

We are confident we can then get the recognition we deserve, as we do take pride in providing great care for our residents and their families and we will continue to ‘go the extra mile’ as stated by one of our relatives this week.

Myself and Simon would like to take this opportunity to thank all of you (residents, relatives and visiting professionals) for your support and positive comments since the inspection.

To our staff we want to say thank you. Your dedication and hard work is obvious for all to see and this was also acknowledged by CQC.
Some of you found the day difficult and upsetting as I did myself but rest assured you are great and valued and we wouldn’t be here without you. So well done.
We have many quality inspections throughout the year which include Warwickshire County Council and Medicines Management Team and you all have developed good working relationships with them and have received positive feedback.

If you have any questions regarding our inspection report please do not hesitate in contacting myself or Simon. We will be discussing the report in full at our next resident/family/friends meeting.

Kind regards

Chrissie Phelan (Manager)
St Mary’s Nursing Home

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