St Marks Residential Care Home

Updated 10 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

St Marks Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Marks Residential Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 6 February 2023 and ended on 6 March 2023. We visited the service on the 6 and 8 February 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection, which included the provider’s action plan to drive improvements. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with the registered manager who is also the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We also spoke with 5 members of staff including the deputy manager, care staff, the cook and the activity coordinator. Also, a visiting hairdresser and a contractor.

We met everyone living in the service, sat and had informal chats with 5 people, and observed people interacting with staff. We reviewed a range of documents and records. These included people’s care and support plans, and medicine records, policies and procedures, staff personnel records relating to recruitment, training, development and supervision, and records relating to the running of the service.

We spoke with 6 people’s relatives to hear their views of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence we found. The registered manager also sent further information, including evidence of action taken after we fed back on areas that needed to be improved. This included reviewed care plans, and risk assessments.

Updated 10 June 2023

About the service

St Marks Residential Care Home is a residential care home providing accommodation and personal care for up to 17 people aged 65 years and over, in one adapted building. The service provides support to people who are vulnerable due to their age and frailty, including varying levels of dementia related needs. At the time of our inspection there were 14 people using the service.

People’s experience of using this service and what we found

This inspection found improvements continued to be made across the service. This was reflected in the positive comments we received from people using this service and their relatives.

Although this inspection showed on-going improvements, not having effective governance systems in place has impacted on the service achieving an improved rating.

The provider’s governance systems were still not strong enough to demonstrate how the management of the service was able to independently identify and act on risk, which placed people at risk of harm. Or, have effective planning in place to demonstrate how they are going to achieve and sustained improved ratings and ensure people receive good quality and safe care at all times. This is especially important as the service has not achieved an overall good rating since 2015.

The provider has taken action to address breaches in regulation, but because the governance systems have not been strong enough, it has led to repeated, or recurring breaches.

The management were reactive during the inspection to address issues we brought to their attention, which had not been identified through their own quality assurance checks.

Where a person’s relative felt staff provided safe care, they also commented that they could only go by what they saw when they visited. Another relative told us about the ongoing improvements in the quality of food, activities, environment, management, and staff. The relative said, “They’re all very friendly and lovely.”

Throughout the inspection, we saw positive relationships between people and the staff who supported them. Also, we saw the friendships forming between new and existing people using the service, as they shared their life experiences and interests.

Staff were motivated and took pride in telling us where they had been able to put their training into practice to support people’s welfare. Improvements were still needed in planning training, how they can make resident meetings more inclusive and driving improvements. We have made recommendations to the provider regarding these areas.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update.

The last rating for this service was requires improvement (published 5 January 2023) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service remains rated requires improvement

At this inspection we found some improvements had been made, with the provider no longer in breach of Regulations 9 and 18. However, they remained in breach of Regulation 17, and a new breach of Regulation 12.

This service has been in Special Measures since April 2021. During this inspection the provider demonstrated that improvements have been made.

The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

This service has been rated requires improvement for the last 2 consecutive inspections.

At our last inspection we made recommendations which covered recruitment, taking guidance from reputable sources to support people with their communication needs, the provider’s complaints policy, and people’s end of life experience.

At this inspection we found the provider had acted on the recommendations. Improvements had been made to the provider’s recruitment application forms to include a full employment history. Information for people was being produced in a clearer font and size, to make it easier to read. Incorrect information given in the provider’s complaints procedure had been amended. Our next inspection will enable us to see how the end-of-life training being attended by staff in May 2023, will be used to enhance people’s experience.

Why we inspected

This inspection was carried out to see what improvements the provider had made.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Marks Residential Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

At this inspection we found breaches of regulation relating to risk management and having effective governance systems in place, to ensure continued improvements.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress.