- Care home
St Marys
Report from 23 December 2025 assessment
Contents
Ratings
Our view of the service
Date of assessment: 13 January 2026 to 5 February 2026. St Marys is a residential care home service providing support to older people, and people living with dementia. This service is registered to accommodate up to 23 people. At the start of the assessment the service was providing care and support to 18 people at the location. This assessment was unannounced which means the provider was not told an assessment was going to be starting beforehand. The service was previously inspected and rated good overall, following a comprehensive inspection carried out on 15 January 2018 (published on 22 February 2018).
During this assessment, we identified shortfalls in the way the service was managed. We found the provider was in breach of the legal regulation relating to safe care and treatment and good governance due to concerns identified with employment records, training records, recruitment files, daily notes, overall management oversight, and people’s environment which placed people at risk of harm.
Staff knew people well, and we observed warm, genuine interactions that reflected a strong, ‘family like’ culture within the home. There was a dog in the care home which was a comforting companion for people and their visiting relatives. Relatives consistently told us they had confidence in the staff team and felt their loved ones were well cared for. The registered manager was visible, approachable, and committed to improving people’s experiences. People benefitted from kind support, meaningful engagement, and stable relationships with long-standing staff.
However, during this assessment we found areas where improvement was needed to ensure the service consistently provided safe and well led care. Daily notes and other care records were not always completed in a timely way, which meant important information about people’s wellbeing and care was not always available to guide staff decision making. This increased the risk that early changes or concerns in people’s health and support needs could be missed.
We also identified environmental safety concerns that had not been recognised or addressed through existing checks. These included unsecured tall furniture, unrestricted windows, overloaded electrical extension leads, a bed stored unsafely on the landing, and hot water temperatures that remained above safe limits despite being identified in a 2023 risk assessment as being an issue. These concerns showed gaps in environmental monitoring and increased the risk of avoidable harm.Governance systems were not always effective. Audits were completed but lacked the depth needed to identify the concerns we found during the assessment. Shortfalls in recruitment records, training oversight and quality assurance processes meant leaders did not always have effective oversight of the service. This resulted in missed opportunities to identify risk, drive improvement, and ensure systems were reliable.
Despite these concerns, the registered manager and provider were responsive to feedback and took prompt action when concerns were raised. We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
During our assessment, where possible, we spoke with people who lived at the service and their relatives. We did observations on the day of our site visit to help capture the experiences of people living at the service. We observed staff treat people with kindness and dignity, including when using equipment such as a hoist, to help with lifting people.
Relatives told us they felt people were being safely cared for and told us people had the equipment they needed, with staff who knew how to use it. Relatives told us they found it more important that their relative was being well looked after by caring, hardworking staff than in a modern facility. Relatives told us that rooms were clean and that efforts were always made to assist people with washing and showering. They said staff were kind and caring and had a good relationship with residents. The home was described as a friendly, welcoming, and comfortable place. Relatives consistently provided positive feedback across all areas, highlighting the caring nature of the home. One relative said, “[Relative] knows the staff personally and they know [relative]. They have proper banter together; the interaction [relative] has with all the people there is really fantastic for them.”
Relatives told us that if people became ill, help was sought promptly. Relatives told us that if they had any concerns, they would be able to raise their concern with the registered manager or other staff members and that it would be dealt with. One person told us, “[registered manager] is very open and efficient; any concerns I have I can raise with them, and they get them sorted out.”
Efforts had been made to make the environment ‘dementia friendly’ with assistive signs and tools to enhance people’s quality of life and help people to be as independent as possible. One relative said, “There is a special something here. When we went to look at care homes we didn't come here automatically. We looked at a few places and the more we looked we were drawn back here.”