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CQC report explained · a nursing home, run by English Dominican Congregation Trust

St Mary's Nursing Home Margaret Street Stone

Margaret Street, Stone, ST15 8EJ

Goodpublished 10 July 2025, 13 months ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The latest report, explained

What inspectors found, February 2024

Rated Requires Improvement; inspectors found caring staff and safe medicines management, but some environmental risks and weak quality checks needed action.

This was an unannounced inspection on 7 and 8 December 2023. Inspectors spoke with people, relatives, staff and professionals. They observed care and checked care records, medicines, recruitment files and management records.

The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. Hot radiators and pipes, windows on upper floors and an unlocked cupboard containing hazardous items created risks. There were also some gaps in records for medicines given when needed. The home acted quickly when inspectors raised these concerns, and no one had been harmed as a result.

People and relatives said they felt safe and well cared for. Inspectors found enough staff, suitable recruitment checks, a clean home, generally safe medicines management and an open, supportive culture. However, the quality assurance systems had not found or dealt with some risks before the inspection.

What inspectors praised
  • People felt safe

    People and relatives consistently said they felt safe and well looked after. Staff understood safeguarding and knew people's needs.

    People and relatives consistently felt safe living in the home and felt positive about the care they received.from the report
  • Enough suitable staff

    Inspectors found enough staff to keep people safe. Recruitment included checks on employment history, references and criminal records.

    People were supported by enough suitably recruited staff.from the report
  • Clean environment

    The home was clean and tidy, with no unpleasant smells. Inspectors saw domestic staff cleaning during the day.

    The home was clean and tidy, with no malodours.from the report
  • Positive culture

    People, relatives and staff spoke very positively about the management team. People felt able to raise concerns and believed they would be acted on.

    The culture of the service was open and inclusive.from the report
  • Learning from incidents

    Accidents and incidents were reviewed, with actions recorded. The home also looked for patterns and retrained staff when serious incidents occurred.

    There was an analysis of accidents and incidents monthly to check if there were any trends and further improvements which could be made.from the report
What inspectors were concerned about
  • Hot surfaces

    serious

    Some radiators and pipes were not covered or temperature-limited. This created a possible burns risk.

    Hot radiators and hot pipes were not always covered, or temperature limited, to ensure they could not pose a burns risk to people.from the report
  • Upper-floor windows

    serious

    Some windows on upper floors did not have suitable restrictors. This left people at risk of falling from height.

    Windows on upper floors were not always appropriately restricted which left people at risk of falling from height.from the report
  • Quality checks missed risks

    serious

    The home's checks had not fully identified or dealt with environmental risks, access to hazardous items and some medicines recording omissions. This led to a breach of Regulation 17.

    Quality assurance systems in place had failed to fully identify and act on concerns with hot radiators and pipes, windows not being appropriately restricted, access to hazardous items and some minor medicines omissions.from the report
  • Medicines records

    needs fixing

    There were some omissions in information and records for medicines given when needed. Inspectors said no one had been harmed and immediate action was taken.

    Some minor improvements were needed regarding documentation around 'when required' medicines and the support being offered to 2 people around some medical equipment.from the report
Questions to ask them, based on this report
  1. 01What action has been completed to cover or temperature-limit the hot radiators and pipes?
  2. 02How are upper-floor window restrictors now checked and maintained?
  3. 03How is the cupboard containing hazardous substances and items kept locked?
  4. 04How are medicines given when needed recorded, including the reason and outcome?
  5. 05What action plan was sent to CQC, and what checks now show that the previous risks have stayed fixed?

This inspection focused on risks linked to Safe and the management systems linked to Well-led; the report does not give ratings for Effective, Caring or Responsive. This explanation was written from the published report of 16 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of St Mary's Nursing Home Margaret Street Stone

7 rated inspections over 8 years: the service has improved, from Inadequate to Requires improvement.

  1. February 2024Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Requires improvement

    Read what inspectors found at St Mary's Nursing Home Margaret Street Stone

  2. January 2022Goodstayed Good
    Safe: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. September 2019Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  4. August 2018Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  5. February 2017Requires improvementstayed Requires improvement
    Safe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. October 2016Requires improvementup from Inadequate
    Safe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  7. May 2016Inadequate
    Safe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  8. August 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. January 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. December 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  11. May 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  12. January 2011

    Registered with the Care Quality Commission on 4 January 2011.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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