5 September 2022
During an inspection looking at part of the service
St Mark’s Court is a care home providing personal and nursing care to up to a maximum of 60 people. The service provides support to older people including people who live with a dementia. At the time of our inspection there were 43 people using the service.
People’s experience of using this service and what we found
At our last inspection the provider had failed to robustly manage the risks relating to the health safety and welfare of people, including managing risks to people’s nutrition and pressure area care.
At this inspection improvements had been made and the service was no longer in breach of the regulation good governance as systems had improved to monitor the quality of service provision.
We have made a recommendation that the provider continues to make improvements to governance including menus, and as a result of people’s feedback to ensure person-centred care is provided.
Records now provided detailed guidance to assist staff to deliver care and support to meet people’s needs safely. Risks were assessed and mitigated to keep people safe. Staff recruitment was carried out safely and effectively.
An infection control system was in place. However, not all areas of the home were well-maintained or clean and there were signs of wear and tear.
We have made a recommendation about continuing with the programme of refurbishment in a timely manner, ensuring the environment is appropriately designed to meet all people’s needs and an appropriate standard of hygiene is maintained.
The provider was monitoring the use of PPE for effectiveness and people’s safely.
All people and relatives were complimentary about the care provided by staff. They trusted the staff who supported them. They said staff, although, “very busy”, were kind and caring and supportive of people and their families. Their comments included, “All the staff are lovely” and “The staff are very friendly and extremely welcoming."
Staffing capacity was sufficient to ensure people's needs were met in a safe way. People's feedback was staff were "very busy."
We have made a recommendation the provider continues to keep staffing levels and staff deployment under review to ensure people receive timely and person-centred care.
Systems were in place for people to receive their medicines in a safe way.
There was evidence of collaborative working and communication with other professionals to help meet people's needs.
The staff team provided support discreetly and with compassion. People’s privacy was respected, and people were supported to maintain contact with relatives.
There was a cheerful atmosphere at the service. One relative commented, “The home has a very homely feeling.”
Staff spoke positively about working at the home and the people they cared for. Staff said the manager was very approachable and they were supported in their role.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
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 14 January 2022) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
We carried out an unannounced inspection of this service on 3 November 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
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.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Mark’s Court on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.