Marantomark Limited St Mark's Care Centre€¦ · 02 August 2016 03 August 2016 10 August 2016 Date of publication: 06 October 2016 Overall rating for this service Inadequate Is the

1 St Mark's Care Centre Inspection report 06 October 2016

Marantomark Limited

St Mark's Care CentreInspection report

Delaunays RoadSaleCheshireM33 6RX

Tel: 01619622032

Date of inspection visit:02 August 201603 August 201610 August 2016

Date of publication:06 October 2016

Overall rating for this service Inadequate

Is the service safe? Inadequate

Is the service effective? Inadequate

Is the service caring? Requires Improvement

Is the service responsive? Requires Improvement

Is the service well-led? Inadequate

Ratings


Summary of findings

Overall summary

St Mark's Care Centre (St Mark's) is a large purpose-built care home located in the Sale area of Trafford, South Manchester. The home provides nursing and residential care for up to 62 people including people living with dementia, enduring mental health needs and acquired brain injury and consists of five units or suites across two floors: Walton, Walkden, Worthington, Woodheys, and Ashton. Ashton suite was not yet admitting people.

Each suite has two lounges, a large main lounge and a smaller quiet one, and dining/kitchen facilities. Each room has its own toilet and shower but there are communal toilets and bathrooms on each unit. The main kitchen, laundry facilities and a hairdresser's salon are situated in the basement area of the home.

St Mark's also has a large and well maintained accessible garden with several seating areas. We identified possible risks to people who may access potentially unsafe areas such as stairwells if they entered the building from the garden. We also saw that residents living in the ground floor suites may be at risk from other residents who could access these suites from the garden.

This inspection was the first one done since the service had registered with the Care Quality Commission (CQC) in July 2015 and it took place on 2, 3 and 10 August 2016. The first day of inspection was unannounced. There were 47 people living at the home when we visited.

There was a registered manager responsible for the day to day operation of the service. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

We found breaches in the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services inspecial measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements withinthis timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varyingthe terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another


inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We received mixed views on whether the service provided safe care. Some relatives said they felt St Mark's was a safe environment whereas others told us they were unsatisfied with the level of care and support their relations received.

Staff did not receive any training in safeguarding vulnerable adults so we could not be sure that they were aware of the various types of abuse. However staff told us they would report any suspected abuse to the nurses. We saw that there was a policy in place to guide staff in safeguarding people from harm. However this policy needed to be updated with accurate contact information so that staff would be guided accordingly to raise concerns. These issues raised concerns about how staff would respond to potential riskswhich could affect people's safety and wellbeing.

Risk assessments were vague and lacked person-centred information to help staff minimise or control identified or potential risks. We noted that risk assessments needed to be reviewed and updated more consistently. This meant that people were still at risk because staff were unaware of their current circumstances.

There was a system for reporting on incidents and accidents that took place within the service. However these reports did not always provide sufficient details on how the incident was managed and what restraintswere used to de-escalate the situation. This would make it difficult for the service to learn and improve from previous incidents. From the way in which forms were completed, it was also apparent that the registered manager was not always aware of what incidents had taken place. This meant that more people may be at risk than the manager was aware of and overall people's wellbeing would be affected.

Safe recruitment practices were in place with the service ensuring that all security checks and references were validated before staff were employed. This helped to ensure that only suitable applicants were employed to work with vulnerable people. We saw that the service did monthly checks on their nursing staff to ensure they remained authorised to work as a registered nurse. Staffing levels in the main were adequate.We did notice that one of the units appeared to be low on staff during our inspection. These gaps were filled by agency staff members.

The management of medicines was satisfactory. We saw that only nursing staff were allowed to administer medicines. Medicines were kept in a locked room near the nurses' stations on all suites. We noted that protocols for PRN or as required medicines needed to be implemented consistently. Covert medicines were administered at the service and we checked that the appropriate best interest meetings and decisions were in place.

People at St Mark's had personal evacuation plans in place. This would help to ensure their safe evacuation from the premises in the event of an emergency. The care home was well maintained and kept clean. We saw that staff observed good hygiene practices such as wearing personal protective equipment and washinghands accordingly. We saw that the majority of staff had not done any infection control training. We also


saw that the service had received a poor score (under 50 per cent) on their infection control audit done in April 2016. Maintenance records indicated that the appropriate checks had been done. However the health and safety officer told us that no fire drills had been carried out since the home opened in 2015.

St Mark's did not always work within the principles of the Mental Capacity Act 2005 (MCA). The service did not always undertake assessments on people known or suspected to lack mental capacity to consent to care and treatment. There was a lack of knowledge and understanding about the impact this legislation could have on people's consent to care and support since staff had not had training on MCA and Deprivationof Liberty Safeguards (DoLS). This meant that people could be receiving care or support where consent had not been obtained in the correct way. The management of DoLS was somewhat disorganised and we found that many of the staff were not sure which residents were subject to a DoLS. This meant that people could potentially be deprived of their liberty illegally or were not treated appropriately because staff were unawareof the conditions of their DoLS.

There was no adequate induction and mandatory training. We did not see evidence of service specific training being done in areas such as acquired brain injury, dementia awareness and de-escalation and distraction techniques. This meant that staff did not have the right skills to support people effectively and safely. Training in mandatory areas was being arranged and done during our inspection. Staff supervision and staff meetings were sporadic but we saw the reinstatement of staff meetings on two of the suites duringour visit. Regular supervision and staff meetings would give staff the opportunity to discuss service specific issues and help them improve outcomes for people living at St Mark's.

People and their relatives gave us mixed reviews on the quality of the food at St Mark's. Some told us that the quality had improved since they had made a complaint and others said the food was appalling. We wereunsure to what extent people's choices had been incorporated into the weekly menus. The provider organisation had outsourced the food provision to an external catering company though the meals were prepared at the home. This arrangement was being revisited with a view to changing the provision.

St Mark's was a new and purpose built care home but we found the environment was not dementia-friendly. We found that people's independence was not supported because the decoration and signage was not adapted to suit their needs. This meant that people's quality of life and wellbeing was adversely affected. Wenoted that people's rooms were personalised to their own tastes.

We saw that people at St Mark's had good access to a range of healthcare professionals such as podiatrists, opticians and GPs.

People and their relatives told us that generally the staff were pleasant and caring. We observed that some staff treated people with dignity and respect. The more established St Mark's staff knew people well and could tell us about people's histories and what their preferences were. Some relatives told us and we observed that agency workers were not always attentive and did not know the people they were caring for. We observed good interactions and relationships between people and staff on some of the suites but we also saw undignified practice which we felt did not demonstrate the qualities of a caring organisation. From some care plans we could see that people and their relatives had active involvement in planning the care delivered. We did not see any specific evidence that the service provided end of life care. The registered manager told us that they were currently doing the six steps end of life pathway training and that this training would be cascaded to other staff members.

Prior to admission, the service conducted an initial assessment to ensure that the care home was able to meet people's needs. We found inconsistencies in the way care plans were developed across the care home.


We saw that some care plans were comprehensive and person-centred, containing personal histories and preferences. Other care plans we reviewed were not always easy to follow and lacked sufficient details to guide staff to provide the required care.

The service employed an activities coordinator however during our visit we did not see many activities taking place. We saw a draft programme of activities that had been developed to help structure the activitiesprovided at St Mark's. We were told this programme would be implemented shortly. This meant that people were not engaging in meaningful activities which could enhance their quality of life.

Relatives told us they would raise concerns with the registered manager if required. We saw that most complaints raised over the period April 2016 to August 2016 had been actioned in a timely manner. We noted that St Mark's did not have an established feedback mechanism such as surveys to ensure they knew what people felt about the service and to help the organisation improve. We were told that it was the home's intention to establish a residents' forum.

We were told that the registered manager was very approachable and that staff were always professional and courteous.

We saw no evidence that the provider organisation had implemented the adequate management systems to help ensure effective operation, communication and accountability within this service. There were no quality assurance systems in place to identify any gaps that required improvement and to help ensure that safe and effective care was being provided. Monthly reports of incidents and accidents and restraint practicewere undertaken but we saw no analysis of this information to identify areas for improvement or training needs.

There were policies and procedures in place to give guidance to staff. However several of these policies contained inaccurate information and required review.

The provider organisation and management team did not have effective oversight of the overall care provision at St Mark's. This meant that the service was not being managed effectively to help ensure the livesof people at St Mark's were not adversely affected.


The five questions we ask about services and what we found

We always ask the following five questions of services.

Is the service safe? Inadequate

The service was not safe.

Incidents and accidents that occurred were not always reported to the local authority safeguarding team and to the Care Quality Commission. We did not see evidence that the registered manager had oversight of all incidents that took place across the care home.

There was no safeguarding training in place to help ensure people were protected from abuse and that staff were aware of the types of abuse and how they could keep people safe. The service's safeguarding policy and procedures contained inconsistent and inaccurate information so that staff did not have clear guidelines to follow.

People's risk assessments did not contain up to date and accurate information to help guide staff to manage risks and provide safe and effective care and support to people when they needed.

In the main, medication administration and storage was good. We noted that the storage room temperature on one suite was too warm. We noted that some people on 'as required' medications did not have protocols in place.

The care home was well maintained and clean. We observed thatstaff followed good hygiene practices and wore personal protective equipment such as gloves and aprons appropriately. The service had recently made one of their nurses the infection control lead with responsibility for ensuring good practice in infection control and prevention and had recently started conducting infection control audits.

Is the service effective? Inadequate

The service was not effective.

The service was not working within the principles of the Mental Capacity Act (MCA). We did not see evidence that consent to care had been obtained. Staff had not had any awareness training in MCA and Deprivation of Liberty Safeguards and were unfamiliar


with their duty of care regarding this protective legislation.

The staff induction and mandatory training offered was not robust and did not adequately prepare staff for their role. Staff we spoke with confirmed that they had had little or no induction training and no service-specific training. Staff currently received sporadic supervision.

The environment was pleasant and modern but the design was not dementia-friendly and did not maximise people's independence. People's rooms were personalised to their own tastes and contained personal mementos and other effects.

The quality of the food provided was variable. Several relatives had made complaints and some said that this had caused an improvement. We did not see any evidence that people were able to influence the menu options provided nor did we see evidence that the kitchen staff were aware of special diets including allergies.

People using the service had access to a range of health care professionals subject to a person's needs. Care plan records we looked at provided evidence that people using the service had accessed a range of health care professionals including: GPs; district nurses; opticians and chiropodists.

Is the service caring? Requires Improvement

The service was not always caring.

People and their relatives told us that staff at St Mark's were pleasant and kind. We observed that the more established staff knew people well and knew their preferences.

From some people's care records we could see that people and their relatives were involved in the care planning. However some relatives told us they had not been involved in the care planning process.

We saw some positive interactions between people and staff. However we did note that some interactions between people and staff were more task-oriented and that staff did not engage with people in meaningful ways. This did not demonstrate a caring approach.

Is the service responsive? Requires Improvement

The service was not always responsive.


Not all care plans were person-centred and most needed reviewing since they did not contain up-to-date and accurate information about people's needs.

We saw that most complaints were actioned in a timely manner; these included issues about care provided and the quality of the food. We saw that members of staff had also raised complaints. We noted however that one complainant had not received a response.

There was a lack of activities and recreation provided at the home to stimulate the people living there.

Is the service well-led? Inadequate

The service was not well-led.

The service did not have any quality assurance and audit systems in place to monitor the care and support provided. This meant that the manager and owner had no effective way of knowing that the care provided was always of a good standard.

The provider had developed a set of policies and procedures to help staff function in their caring role but we found that the policies had not always been adapted to reflect what was required for the home and some documents contained inaccurate information.

Staff meetings had been reinstated recently and these should help to ensure that the service ran smoothly. We noted that not all suites had yet held a staff meeting/


St Mark's Care CentreDetailed findings

Background to this inspectionWe carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 2, 3 and 10 August 2016 and was unannounced. The inspection team consisted of three adult social care inspectors. This was the first inspection since the service had been registered with the Care Quality Commission in July 2015.

We considered information we held about the service, such as concerns raised by members of the public, notifications and safeguarding concerns. A notification is information about important events which the service is required to send us by law. The provider did not complete a Provider Information Return (PIR) prior to this inspection since the inspection had been brought forward due to information we received. The PIR asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We contacted various stakeholders such as local authorities, Clinical Commissioning Groups (CCGs) and Healthwatch to find out what information they held about this service. Healthwatch is an organisation responsible for ensuring the voice of users of health and care services are heard by those commissioning, delivering and regulating services. Trafford Council commissioners told us they had conducted a joint monitoring visit with the Trafford CCG in late July 2016. We were told this was a themed monitoring visit and focussed on end of life care and staff recruitment; they did not identify any major concerns in these areas. We also spoke with and reviewed information sent to us by the infection control lead at the NHS Trust, Trafford division. They told us about the concerns they had regarding how little remedial action had taken place between their first inspection done in October 2015 and the second one done in April 2016.

We looked around the building and observed mealtimes and interaction between staff and people living in the home. We carried out an observation known as a Short Observational Framework for Inspection (SOFI). This is a way of observing care to help us understand the experience of people who cannot easily express their views to us.


During our inspection, we spoke with three people who lived at St Mark's and eight relatives who were visiting, the nominated individual and the clinical nurse lead, six registered nurses, seven care staff, including three agency workers, one laundry assistant and the head chef. On the second day of our inspection we spoke with a GP who was visiting a resident and a tissue viability nurse. We were unable to speak with the registered manager until the third day of our inspection as they were on annual leave when we first visited.

We observed the way people were supported in communal areas and looked at records relating to the service including eight care records and daily record notes, medication administration records (MARs), six staff recruitment files, training records, accidents and incidents, policies and procedures as well as information about the management and operation of the service.


Is the service safe?

Our findings When we asked if the service was safe the response was mixed. Some people and their relatives told us that St Mark's was a safe environment and staff supported people to keep safe. One person told us, "Yes, I feel very safe here"; another person told us that the care staff knew their needs well and that helped to keep them safe. Two visiting relatives told us the staff and environment at St Mark's gave them "peace of mind". Another relative told us that their relation had one-to-one support and this reassured them that their relation was being supported in a safe manner. However, we spoke with two relatives who were not satisfiedthat the care home was providing safe care and support to their relations. One relative had raised several safeguarding concerns with the local authority and the Care Quality Commission.

We noted that access around the care home was limited by the use of an electronic fob. This meant that people were protected from accessing potentially unsafe areas such as stairwells. However we noted that it was possible to do so if a person entered the building from the garden. We saw an instance where a resident did just that. We noted that a member of the domestic staff got involved when we expressed our concerns and subsequently escorted this person safely back into the garden and stayed with them. We raised this issue with the nominated individual who said they would highlight this to the registered manager. We also recognised that residents living on the ground floor suites were potentially at risk from other residents who could access these suites from the garden.

On one of the suites, we noticed that a makeshift gate was put in place to restrict people's entrance to the nurses' station. On the first day of our inspection, we observed two separate attempts by one person to climb over the gate. We saw that on both occasions a member of staff was on hand to help this person and to prevent them from falling. On the second day, a resident tried to climb over the gate but no staff were available to assist at the time. We intervened and assisted the person to a safe position. We discussed the risks this gate presented to the nominated individual. They removed the makeshift gate immediately and told us the matter had been reported to the maintenance team who would replace it with a more suitable alternative.

These environmental concerns were a breach of Regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We checked to see what training the service had in place to ensure that staff had appropriate knowledge on keeping people safe and knew what to do if they suspected abuse was taking place. From training records, we noted that staff had not received any training in keeping vulnerable adults safe. Staff we spoke with said they would report any abuse to the nurse in charge. They told us their knowledge of safeguarding was gained from previous training and experience at other homes. This meant that the service had not taken the necessary steps to help ensure that staff were competent in and aware of how they would keep people safe.

We saw there was a policy in place to guide staff in safeguarding people from harm. However, we noted the policy contained contact details for both Oldham and Trafford social services but the out of hours numbers were for Warrington social services. This meant that staff did not have clear and accurate guidelines on

Inadequate


which local authority they should contact if they needed to report a safeguarding incident.

These examples constituted a breach of Regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as people were not adequately protected from abuse because staff did not have appropriate training in safeguarding vulnerable people and the service's safeguarding policy and procedures were inaccurate.

On the third day of our inspection we were told that safeguarding training had been scheduled and was currently taking place.

We saw that the service had systems in place to record incidents, accidents and falls. Staff we spoke with were able to explain the process they followed to report any incident that occurred. We were told that reports were either hand written or inputted on the computer, and then they were sent to the manager. However, we found two examples of incidents that had been documented but we saw no evidence that the registered manager had been informed of them. We noted the process did not include reporting externally to the local authority or to the Care Quality Commission.

During our inspection we observed many incidents of people expressing behaviours that challenged others. For example, on the first day of our inspection we observed one of the residents grab the arm of another resident while they were seated next to each other at the nurses' station. We saw that this led to an altercation between them. We noted staff were quickly on hand to de-escalate the incident. However, one member of staff commented, "This is a regular occurrence on this unit." We saw on several occasions that people were displaying signs of physical aggression towards staff and at times towards other residents. We spoke to a staff member who informed us they had recently sustained an injury on that unit when attempting to de-escalate a "challenging incident" with a resident. This staff member informed us they had never received physical intervention or breakaway training.

From the records we reviewed, we noted that incident forms did not always provide detailed information on how the incident was managed and what restraints staff used to de-escalate the incident. We highlighted this issue to the nominated individual and the clinical nurse lead. The clinical nurse lead told us they recognised the current process was not working well and they showed us their analysis of how incident forms were being completed. We were told that this piece of work highlighted where the gaps were and that these would be addressed by lead nurses in supervisions with staff and at staff meetings.

We asked for evidence of how the service was recording and monitoring safeguarding referrals made to the local authority and the Care Quality Commission. The registered manager provided copies of eight safeguarding referrals that had been made to Trafford social services but no evidence of the outcome of each referral and any follow-up action taken.

While we noted there were systems in place to record and report safeguarding and other incidents, and accidents, these systems did not appear to be effective in protecting people from abuse and improper treatment. These constituted a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at eight people's care plans to see if any risk assessment had been done in relation to the care and support they received. The care files we looked at showed completed risk assessments to assess and monitor people's health and safety. Risk assessments help to keep people safe by providing specific and detailed guidance to care workers making sure they provide appropriate and safe care and support to people. We saw risk assessments in areas such as falls, nutrition, mobility and pressure relief. We found that


some risk assessments were vague and lacked person-centred information on the actions required to minimise or control actual and potential risks. For example, we observed one person refusing to take their medication. We were told by the nurse that this was a regular occurrence with this person and happened daily. We noted this information had not been recorded on this person's medication care plan nor was there any information concerning the person's refusal to take medicines and what potential risks to the person's health and welfare were involved. In two people's care records, we saw that they had been assessed as high risk of developing pressure ulcers but that their risk assessments had not been reviewed since June 2016. This meant that these people were potentially still at risk because there was no evidence to support that their current condition had been reviewed and that care staff did not have up to date and accurate information to support them safely and appropriately.

These examples constituted a breach of Regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with reference to 12(2)(a)(b).

Through discussion with staff and examination of records, we confirmed that there were satisfactory recruitment and selection procedures in place which met current regulatory requirements. We looked at six staff records for staff, five of whom had been recently recruited to St Mark's. In all six files, we found that there were application forms, references, medical statements, disclosure and barring service (DBS) checks and proof of identity including photographic identification. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with vulnerable people who use care and support services. We found that the service had satisfactory recruitment processes in place to help ensure they employed appropriate staff members. However in one staff's file we noted that one of the references gave a personal email address. We saw that the registered manager had made checks to ensure that the referee was valid. We suggested to the manager that they could contact the human resources department of the organisation to request a reference.

We saw records to show current registrations were in place for all nursing staff. These were checked monthlywith the Nursing and Midwifery Council (NMC) to ensure all nurses remained authorised to work as a registered nurse.

Prior to this inspection, we received information that staffing levels were inadequate. We asked the clinical nurse specialist and lead nurses about staffing on each suite. The Clinical nurse specialist told us that there had been some issues relating to staffing levels as a result of staff dismissals and staff sickness. We were toldthat the service used agency staff to cover these absences. We were also told that the service was currently recruiting nurses and care assistants.

Based on our observations on Walton, Woodheys and Walkden Suites we felt that staffing levels were adequate. Both staff and relatives confirmed this. We saw that people were attended to when required and no one was waiting for assistance. The staff members and relatives we spoke with on these suites all said that there were enough staff to manage the needs of people living there. We observed less staff deployed on Worthington Suite and that there were a lot of agency staff working on that suite. We noted this suite accommodated people living with advanced dementia who displayed behaviours that challenged. On the second day of our inspection, we observed that staffing levels appeared to be low on this suite. The lead nurse told us an agency staff member had not reported to work that morning. We noted a replacement worker did not arrive until later that day. Also, we saw that one of the bank staff was requested to complete their fire safety training on that day and no staff member replaced them. This meant that for about one and a half hours in the morning there was only one nurse and four agency care workers available to support twelve people with quite complex health and care needs. The clinical nurse lead told us they were researching staffing dependency tools which would help to ensure that the right levels of staff were


employed across the service at all times

We looked at the management of medicines. We saw that medicines were kept in a locked room near the nurses' stations on each suite. We were told and we saw that only the nursing staff had keys to access this room and that they were responsible for administering medicines. We saw a list of staff responsible for administering medicines, together with sample signatures, available for reference. On some units, we noted that the list needed to be updated since it contained names of staff who no longer worked at St Mark's. We checked that there were appropriate and up-to-date policies and procedures in place for the administration of medicines and found that the provider organisation had developed a suitable policy for staff to reference.

We saw that medication was stored in a medication trolley that was secured to a wall in a dedicated storage room. We saw that there was separate and appropriate storage available for controlled drugs. Controlled drugs are medicines where strict legal controls are imposed to prevent them from being misused, obtained illegally or causing harm. We checked the arrangements for the receipt, storage, recording and administration of medication and found that these were satisfactory. We noted on the Worthington Suite that the temperature recordings in the medication room had not always been completed daily and that the room temperature was in the excess of 30 degrees celsius. According to nationally recognised guidance, the recommended room temperature for storing medicines should not exceed 25 degrees celsius. The senior nurse told us they did not know whether any action had been taken to address this matter.

We noted that there were protocols in place for some PRN (or 'as required') medications for people but nonefor other PRN medicines. PRN protocols provide guidance to staff on when and how to safely administer medicine that is not given as a regular daily dose or at specific times. For example one person had protocols in place for taking one PRN medication but not for another. This person was also prescribed two different medicines for agitation however this was not in their care plan and it was unclear how they should be administered, that is, at the same time or one before the other. This meant that people may not always receive their medication at the time they most needed them.

We asked if there were any people living at St Mark's who were given their medicines covertly. We checked their records and confirmed that best interest meetings had been held to make these decisions. However wesaw no evidence that these decisions had been reviewed since making them.

We saw that people living at St Mark's had personal emergency evacuation plans (PEEPS). PEEPs help to ensure that in the event of an emergency, such as a fire, people would be safely removed from the premises.We were told these documents were updated regularly and we saw they were kept at the nurses' station where they could be accessed easily.

We observed that all suites were kept clean and well maintained. We saw that handwashing facilities were inplace and used and that staff observed good hygiene practices, for example wearing aprons and gloves, when giving personal care and handling food.

We noted from training records that not all staff had received training in infection control. We noted that four out of six domestic staff, the activities coordinator, one maintenance officer and the administrator had received the training in October 2015. We observed a bank staff member wearing jewelry and their finger nails were long and painted. This was not good infection control practice. We brought this issue to the attention of the lead nurse.

In one person's care records, we saw documentation dated March 2016 from a tissue viability nurse stating that the person using the service was MRSA-positive. Staff we spoke with were unaware of this. This meant


that staff were not aware that they should be more rigorous with hygiene procedures or that the person would be at risk if they developed a skin break. The lack of training in infection control in relation to ensuringpeople receive safe and relevant care was a breach of Regulation 12 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We saw that the local division of the NHS Trust had done an infection control audit in April 2016. We noted the service had scored 45 percent and that an action plan had been devised. This meant that the NHS Trust had identified several areas which the service had to address in order to meet infection control compliance standards. We noted that many actions coming out of this audit were still outstanding. We asked the clinicallead what action had been taken by the service. They told us that one of the lead nurses had been appointed as the infection control lead. We saw in the minutes of a meeting of lead nurses held in July 2016 that training support would be sought from one of the provider organisation's other care homes, a proposal for purchasing specialist infection control and prevention equipment such as ultra violet light and hand hygiene kits and the arranging of mock inspections of each suite in preparation for the follow-up NHS Trust audit in October 2016. We noted that the minutes reflected that the infection control lead had taken some action; however there were no records to demonstrate exactly what action had been taken to date. We spoke to the clinical nurse lead about this and they told us they were in the process of setting up systems to ensure regular infection control checks were done. On the last day of our inspection the clinical nurse lead told us the service had done its first infection control audit the night before. However, we did not see evidence of this.

We saw the laundry was well equipped and well organised. We saw that there was a clear system in place to keep dirty items separate from the clean ones. Laundry staff we spoke with had been trained in infection control and understood their responsibilities in relation to infection control and prevention in the laundry setting. They told us however there was need for clear processes regarding which staff were responsible for returning people's items after they had been laundered. They also told us they had made suggestions to management about how the laundry room could be better equipped to manage clean items such as baskets and cubbyholes for smaller items such as socks and underwear.

We spoke with the staff responsible for maintenance and health and safety and looked at records including those for legionella control, water temperatures, fire safety, hoisting equipment and gas safety. We were satisfied that the appropriate checks were done. We saw that pressure relieving mattresses were hired and serviced by the company providing them. We did not see any record of checks on window restrictors but there was evidence that a couple that were broken had been replaced. The lead officer for health and safety told us they were also the fire trainer and that they had done fire safety training for the staff and had more training dates planned. During our inspection, we saw that additional training had been planned for those staff members who had not already done fire safety training. The health and safety lead officer admitted that no fire drills had been carried out since the care home opened. They told us they would address this.


Is the service effective?

Our findings The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under MCA. The authorisation procedures for this in care homes are called Deprivation of Liberty Safeguards (DoLS). The Care Quality Commission (CQC) is required by law to monitor the operation of DoLS. We checked to see if St Mark's was working within the principles of the Mental Capacity Act 2005 (MCA).

We saw that there were corporate policies in place relating to the MCA, best interests, and DoLS. We saw thatassessment documentation had also been produced to enable staff to undertake an assessment of capacityin the event this was necessary. We saw examples of where the service had assessed people's capacity to make specific decisions such as take medications. However we found that capacity assessments did not appear to be systematically done. In most people's care records we did not see capacity assessments and related best interest decisions regarding consent to care despite the information contained in people's care plans that they lacked capacity to make decisions about their care and treatment.

We did not see documentary evidence that people had given their consent to the care they were receiving atSt Mark's. We asked the registered manager about this and they indicated that since people's care plans were stored electronically, the service needed to devise a way to document people's consent. This meant that people were potentially receiving care or support where consent had not been obtained in the appropriate way.

We found the management of DoLS to be somewhat disorganised. Most of the nursing and care staff we spoke with were uncertain as to which residents were subject to a DoLS. We noted on the whiteboard at the nurses' stations on some suites there was a list of people who were either currently or at some stage subject to a DoLS. When we asked nursing staff about DoLS documentation they told us the registered manager dealt with this. We asked the registered manager about the DoLS applications and documentation and they provided us with a list of DoLS applications made to the local authority. However we were unable to verify entries on this list with actual applications made and authorisations received because these documents were not kept in people's care records. On Walkden Suite, we found DoLS documentation for one resident; we noted that this person did not appear on the registered manager's list. Also, we found that staff were not aware of the special conditions associated with this person's DoLS authorisation. On Walton Suite, a person's electronic care records contained a folder labelled DoLs but the folder contained no information toconfirm that an application had been made or whether a DoLS application was necessary.

In another person's care plan, we noted that they lacked capacity to understand that they require treatment and they were not able to give consent. We noted that a DoLS application had not been applied for.

Inadequate


We found staff's knowledge of MCA and DoLS to be mixed in that some staff told us they were aware of the legislation but did not fully understand it and others told us they did not know what the terms meant. Staff told us they had not received any training on MCA and DoLS. The training matrix we looked at confirmed this. This meant that staff did not understand their duty of care in respect of this protective legislation.

We found the service was in breach of Regulation 11(1)(2)(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because it failed to operate within the principles of the MCA.

Views we received about staff capability were mixed. Some of the comments relatives told us were: "Staff arelovely, very willing, but I don't think they are properly trained", "Staff are skilled and know what they're doing" and "Staff are lovely and good at their jobs."

We asked the service about the induction and on-going training provided for staff. We were told and we saw that staff had not received adequate induction training nor was there yet a programme of ongoing training. We looked at the training matrix which indicated that at the time of this inspection all staff had received fire safety and moving and handling training; we noted that some staff (less than 10 per cent) had been trained in de-escalation and release techniques. From other training records, we noted that some staff had completed mental health awareness training; this training was not recorded on the training matrix but was now out of date and needed updating. We saw that no service specific training such as dementia awareness or acquired brain injury training was on offer.

On the first day of our inspection, the clinical nurse lead showed us a training schedule planned for August 2016. They told us training would continue on a rolling basis until all staff were trained. We noted the following training sessions were scheduled to take place: fire safety, safeguarding vulnerable adults, infection control, health and safety, mental capacity and deprivation of liberty safeguards, moving and handling, and an introduction to the Care Certificate. The Care Certificate is a nationally recognised set of standards to be worked towards during the induction training of new care workers. We did not see any evidence of how the service was going to deliver the care certificate training. We saw this schedule also proposed future staff training sessions in the management of violence and aggression, medication management and managing mental health (Recovery Star).

We noted that the training policy indicated the following additional training should be completed within twelve months: management of violence and aggression, infection control, safeguarding, equality and diversity, MUST (Malnutrition Universal Screening Tool), MCA and DoLs (Mental Capacity Act 2005/ Deprivation of Liberty Safeguards), food hygiene, first aid, COSHH (control of substances hazardous to health), medicines, dignity, falls prevention, dementia and challenging behaviour, continence promotion, communication and information governance. We noted that the service contravened its own policy by not providing staff with proper induction training and the additional service-specific training as indicated. In addition to this we felt this policy was not fit for purpose since staff were not well-equipped to safely and effectively attend to the complex needs presented by people living at St. Mark's.

We saw within the training policy that "All staff will have a personal development and training plan." We did not see any evidence of this.

We noted from staff records that supervision was sporadic. Supervision helps to ensure staff have the necessary support and opportunity to discuss any issues or concerns they may have about their role. Some staff told us they had not had a supervision despite being at the service for more than a year. We saw that the service's supervision policy stated that supervision should take place six times a year. Also, we saw that not all relevant staff had had an annual appraisal of their performance. This meant that staff were not given


the opportunity to identify areas for support and professional development which could help strengthen their practice and effectiveness.

Failure to have appropriately trained and skilled staff and appropriate systems in place to manage staff training and professional development were a breach of Regulation 18(2)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People and their relatives gave us mixed opinions on the quality and choice of the food provided at St Mark's. One person told us, "The food's really good and I can have crumpets with Marmite for supper, which Ilike." Another person said, "The food isn't very nice; I would like more spicy food." A relative told us that "meals have improved…food is a lot better now. Before, the portions were small, vegetables hard … staff agreed (with us)." This relative said they had made a verbal complaint which they felt had been listened to. Another relative told us "The food on the menu was awful but (relative) only offered sandwiches as an alternative which were smothered in mayonnaise and I told them numerous times (relative) hates mayonnaise." A third relative said, "The food is appalling – (relative) is supposed to be on a soft diet and it took me three weeks to get them to consistently provide soft food…had to have 2 meetings with the chef. (Relative) likes soup with bread broken into it, but you can't get any bread with the soup." Another relative told us, "I sometimes visit at mealtimes and the food looks ok." Two staff members we spoke with also madenegative comments about the food and they said if people did not want the meal on offer that sandwiches were the only alternative. We also saw two separate complaints made by relatives and nursing staff about the quality of the food.

We were told and we saw that meals were prepared by an external catering company but cooked from fresh in the service's own kitchen. We spoke with the chef who told us meals were freshly prepared each day. Theysaid the catering company provided items for breakfast which were prepared by care staff on each suite. We were able to see that this was the case as the kitchen staff got on with preparing luncheon meals. We saw that menus were provided by the catering company over a four-weekly period. We were told that weekly menus were displayed in the dining room. However we saw that this was not always the case and we noted that weekly menus did not always reflect what was on offer.

We asked how these menus were decided to ensure that people's choices and preferences were reflected in the meal options. The chef told us the menus were based on what people had told the service they wanted and also their observations of what worked well. They said changes to the menus were made based on these observations. We asked about alternative options if people did not like what was on the menu. They told us although the menus stated the only alternatives available were "assorted sandwiches and salad" that they would prepare any meal someone requested provided they had the ingredients in stock. They gaveexamples of cooking other meals (such as pasta dishes or bacon and eggs) for people who did not want what was on the menu that day.

Some people were able to tell us that they had a choice in deciding what they wanted to eat. However, we found no evidence in people's care records to suggest that people's choices had been considered. This did not demonstrate a person-centred approach and was a breach of Regulation 9(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

On the first day of our inspection, we observed the dining experience at lunchtime. On the Worthington Suite, we noted that there were eight people having their lunch in the dining room and the other four peoplehaving their lunch in their bedrooms. During lunch time, four members of staff were assisting people with their meals. Throughout our observation there appeared to be a lack of direction in relation to 'who was doing what'; we observed three staff members in the lounge area discussing who needed assistance with


their meals and which tasks were still outstanding.

We did however observe some good practice from a member of staff who was on hand to reassure one person who was distressed and they appeared to know this person's needs well as they calmed them by singing to them and softly stroking their hand.

We asked the chef if they were aware of persons who required special dietary considerations such as diet controlled diabetes or food allergies and if there was a list kept in the kitchen of these residents. The chef told us they did not have such a list in the kitchen but that they knew which residents required special diets. To clarify this we asked the nurses on duty on Woodheys and Walton Suites which residents were on special diets. We checked with the chef who only knew of one person on a soft diet and it was not the person the nurse had mentioned and they made no reference to a person's allergy to tomatoes. This meant that peoplewere potentially at risk of being given meals that did not suit their requirements. We highlighted to the chef and the service that it would be better and safer practice to have such a list located in the kitchen; this would help to ensure people received the correct meals.

We observed hot and cold drinks and biscuits were made available at various times throughout the day. Thishelped to ensure that people were kept hydrated throughout the day.

We saw that people who were nursed in bed had food and fluid charts. We looked at three of these. We saw that records were kept regarding the amount that people ate and drank when they were at risk nutritionally. We found that they were completed consistently. We witnessed an incident where one resident entered the room of another and drank all of their drinks. This meant that staff would think the person had drunk their own drinks and record on their fluid charts as such. We pointed out what had happened to a staff member who was nearby but had not noticed the incident; they did not respond. We raised the issue with the nurse who had been busy administering medicines indicating our concerns about knowing if people are getting the adequate fluids.

We found that despite St Mark's being a new and purpose built care home, the environment was not dementia-friendly. We noted that people's bedrooms were homely and comfortable having been personalised with their own memorabilia, photos of family, other personal effects and ornaments. We saw that each bedroom had ensuite facilities and there were also communal bathrooms and toilets for people toaccess. Each suite had lounges, and dining rooms with a small kitchen area. On some suites, we noted photographs on people's bedroom doors; this should help people to identify their rooms. However this was not the case on all suites and we observed many people on the Worthington Suite struggling to locate bathrooms and toilets with some people entering other people's bedrooms. On the Woodheys Suite, we did see a large sign saying "Lounge" but other signage was high up on doors and in small letters. Overall, we noted appropriate signage and use of colour schemes had not been established fully to help people living with dementia to identify areas within the home such as main lounge, dining room and communal toilets. The use of pictures and other visual aids can be helpful in promoting the independence and orientation of people with dementia related needs. This meant the service had not adapted the premises to improve people's quality of life and wellbeing. We were informed by the clinical nurse lead that the provider was exploring options to enhance the overall environment to make it more 'dementia friendly' and to assist people to orientate. We were told that a special project group had been established to take this forward.

We saw that St Mark's had a pleasant garden which was easily accessible to people living on the ground floor but not to those living on the first floor unless they had assistance from staff or relatives. During our inspection the weather was fine, however we did not see any effort from staff to take people out or encourage people to enjoy the outdoor space.


We were told that people living at St Mark's were registered with three GP practices in the area. From people's care files, we could see that people had good access to a range of health care professionals including podiatrists, district nurses and opticians. We also witnessed nurses arranging health appointmentsfor residents. During the inspection, we saw four healthcare professionals who attended to provide treatment to people living there. This meant that people's healthcare needs were being arranged when needed.


Is the service caring?

Our findings People living at St Mark's and their relatives told us that in the main staff were pleasant and willing. One person told us, 'The staff are brilliant, they do everything you want them to'.

One relative told us "The staff are all very pleasant, but there seems to have been a complete change of staff this week and they don't know (Person's name's) needs as well. I've also noticed that when agency staff carefor him they don't seem to know what (Person) likes. Another relative said, "This is the best place because I know [Person's name] is looked after. (They) are always well presented."

One of the compliments received by the service stated "I can't believe how happy, cheerful and how well (Person) looks…such a wonderful happy place, all the staff are amazing."

We observed some positive interactions and relationships between people and staff on some of the suites; this included playing games and chatting with them. On some suites however we noted the interactions between people and staff were less relaxed and more task-focussed. For example, we did not observe staff speaking or engaging with people in any meaningful way.

Some relatives told us the staff at St Mark's were genuinely caring and always made made sure their relatives were looked after and had what they needed. We saw the more established staff members knew people's personal histories and their preferences and were able to engage better with people whose behaviours challenged services.

We could see in some cases that people had been actively involved in making decisions about their care. Forexample we saw that one person had made an advanced decision relating to the number of cigarettes they would have each day. We saw that this was documented in their care plan and when we asked them about this they confirmed that that was their decision. However one relative told us, "I haven't seen any care plan for (relative) and no-one's asked me about it." Another relative told us they were certain they had received a copy of their relation's care plan. The care plans we looked at indicated that people and their family members did have some involvement in making decisions about care received. For example, one person we spoke with told us they enjoyed visits with particular family members and we confirmed this was documented in their care plan. We also saw in their care plan that they liked their relative to bring in their dogs for a visit. During our inspection we witnessed this happening.

A compliment received by St Mark's from a relative stated, "(My relative's) privacy, dignity and needs are paramount.They are showered, shaved and moisturised daily." We observed that in the main care staff were kind and treated people in a respectful and dignified way. We saw this when staff knocked on people's doorsbefore entering their bedrooms or asked permission to go into their rooms when people were not in them. We also observed how staff supported people to the dining room, lounge or toilet. We noted that staff assisted people at their own pace and did not rush them. In some instances we observed that care staff keptup a conversation with the person as they went along.

Requires Improvement


We observed several examples of agency staff who neither engaged or interacted with residents while providing one-to-one support to them. We found their practice demonstrated a lack of caring and understanding about delivering person-centred care. We highlighted this to the directors and senior managers of the service when we provided feedback. During our inspection, we also noticed that the communal toilets on some suites were kept locked. We were told this was done as a safety precaution. This meant that someone who needed to use the facilities had to either go back to their own bedrooms or else communicate their need with a member of staff. These examples we felt affected people's dignity and independence, and did not demonstrate caring practice.

We did not see any specific evidence that the service provided end of life care. The registered manager told us that they were currently implementing the Six Steps end of life pathway and that two nurses were alreadytrained in this area. They told us the intention was to cascade this training to other members of staff.

We observed an inconsistent approach to how staff worked and interacted with people on each suite. For example, on some suites people had staff who knew them well and had good interaction with them; whereas on other suites, we observed that staff did not engage with people when assisting them at mealtimes or taking them from one room to another. We felt that this approach did not demonstrate the qualities of a caring service. We felt that this approach did not demonstrate the qualities of a caring service.


Is the service responsive?

Our findings We were told that the service undertook an initial assessment of all people, in consultation with family members where appropriate, before the care home agreed to accept a placement. This meant that the service tried to make sure it was suitable for the person and would be able to meet their needs. We saw that each person's care plan was developed from the initial assessment. However, some relatives told us they had not been involved in the care planning process.

We reviewed the care records for eight people who lived at St Mark's and we found that these plans differed depending on which suite the person lived. We saw two suites had a key worker system whereby nurses were allocated certain residents and they were responsible for updating these people's records. One of the nurses told us that this system was under review since the recent relocation of lead nurses to other suites. We noted that this seemed to have had an impact on reviews not being done when they were due.

We saw that some care plans were person-centred and comprehensive and contained information such as personal histories, likes and dislikes, and triggers for behaviours that may challenge and ways to manage these, and were reviewed monthly. Other care records we reviewed were not easy to follow as they did not follow a consistent approach. Staff we spoke with confirmed this and indicated that this difference made it somewhat difficult to move between the suites. We saw that some care plans did not describe in detail people's life histories and lacked sufficient details that would guide staff to provide the care needed. For example, in one person's plan for personal hygiene said that three to four staff were required "as person resistive to care" but there was no mention of techniques or approaches to try. We also found information relating to other residents in two people's care records and several of the care plans we looked at had not been reviewed. This meant that care plans did not accurately reflect the current care needed. This approach was not person centred and was a breach of Regulation 9(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We noted that the current system of care planning was somewhat disorganised in that some care records were kept electronically and others, such as involvement with healthcare professionals, was kept in paper format. This would make it difficult for staff to easily access the information they needed about a person to help ensure they were providing the right care and support and to maintain a contemporaneous record. Theclinical nurse lead showed us, via correspondence the provider's intention to invest in an electronic care planning system which they felt would help to provide a more consistent approach to how people's care plans were developed.

Our use of the Short Observational Framework for Inspection (SOFI) during the lunchtime period highlighteda lack of direction in relation to 'who was doing what' as we observed three staff members in the lounge area discussing which residents needed assistance with their meals and which tasks were still outstanding. This meant that staff were not supporting people adequately so that they enjoyed their dining experience. We also observed other negative interactions between people and staff members. For example we saw a staff member preventing a person from leaving the dining area by putting their arm across the door on morethan one occasion. We noticed some of the staff did not calmly provide assurances to people who were

Requires Improvement


anxious but guided them back to the dining table without any communication. We also observed an agency staff member standing above one person while assisting them with their meal. We found these interactions undignified and lacking a person-centred care approach. These examples were not characteristic of a responsive service and were a breach of Regulation 9(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During our inspection we did not see much in the way of activities and recreation being provided at St Mark's. On one suite during the morning, we saw one of the care assistants playing a game of draughts with one of the residents. At other times throughout the days we were inspecting, we noted a music channel was playing on the television. One person told me that they enjoyed working in the garden and that they sometimes did a gardening activity. We were told that the service employed an activities coordinator and that they did group and one-to-one activities with people on each unit. We were told the activity coordinatorwas currently being supported by a colleague from one of the other provider homes to develop a more structured programme of activities for people living at St Mark's. We saw a draft programme of activities andwe asked if and how residents had been involved in this process and if activities had been considered to include people living with dementia. The activities coordinator told us they had a good knowledge of people's wishes and likes and read people's care plans to see what activities people would be interested in doing. We were told that the service was looking into ways for care assistants and nurses to get involved in assisting with activities. The lack of meaningful activities and recreation to provide stimulation was a breachof Regulation 9 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Relatives we spoke with told us they would raise concerns if required. Some relatives told us they had raised complaints regarding the quality of the food provided. We saw a record of eight complaints raised over the period April 2016 to August 2016; these included issues about care provided and the quality of food. We noted that one of these complaints had been raised by staff members. We saw that the service followed its complaints policy and actioned each complaint in a timely manner. However in the case of one complaint relating to the food quality we did not see that a response had been made to the complainant. We were told that the service had had some problems with the external catering company; these included staffing issues and that the provider organisation was planning to end the arrangement with them and provide its own meals.

We asked if there was a residents' group at St Mark's. The clinical nurse specialist told us that it was their intention to establish a residents' forum in the near future. This meant that people living at St Mark's and their relatives currently did not have an established mechanism to provide feedback to the service about thequality of care being provided.


Is the service well-led?

Our findings People and their relatives told us the registered manager was very approachable and staff were friendly yet professional. Comments people made about St Mark's included: "It's really good here; I can go in the garden for a cigarette" and "I always get on with the staff; they're very nice." Some relatives we spoke with were happy with the care provided at St Mark's. We saw positive feedback on an independent care sector website from two relatives who wrote comments in January 2016. One relative said, "My (relative) is receiving the very best quality of care at St. Mark's. All staff are professional, courteous and caring. They are happy to answer any questions you might have concerning your loved ones." Another relative commented, "Staff at StMarks are friendly and have made (relative) feel welcome. They are always on hand to answer any questions you have. Staff are taking time to really get to know my (relative) as a unique individual and this is very important to both (them) and us. Thank you."

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had appointed a clinical nurse lead in June 2016 to provide managerial support to the registered manager and also to provide clinical support and nursing supervision to the nursing staff employed at the home.

St Mark's was the newest of three care centres owned by the provider organisation. We saw no evidence thatthe provider organisation had implemented the necessary and adequate management systems to operate effectively and enable them to monitor and improve the quality of service. Over the course of our inspection,we saw that there was a lack of cohesive leadership and effective management, and we saw poor communication across the service. From reviewing documents and talking with staff, we observed that each suite was managed differently and that this affected the day-to-day operation and systems such as care planning and daily recordkeeping. We saw that some units were better organised and that nurses in charge were able to offer some direction and leadership to other nurses, care assistants and visiting professionals. We saw this was not the case on all suites.

We noted the provider organisation had developed a suite of policies and procedures to give guidance and support to staff in performing their caring role. We saw that each suite had its own copy of these documents.We noted that several of the policies we reviewed referred to the provider's other locations and had not been adapted to reflect what applied at St Mark's. Also some of the policies such as the care plan policy and safeguarding policy contained inaccurate or outdated information and referred to documents that were not included in the policy. This meant that these documents were not fit for purpose and provided limited guidance to staff on the service's operational practice.

We asked the service what quality assurance systems were in place, for example care plan and medication audits and spot checks, to monitor that the care and support provided was safe and effective. We were told that care plan and medication administration record audits were done. However with the exception of controlled drugs, we found no evidence to demonstrate that any audits had been undertaken since the care

Inadequate


home had opened.

We saw that the service reported monthly on the incidents/accidents and restraint measures that took placeat St Mark's. However, we noted that there was no analysis of this information to identify areas for improvement and/or training requirements.

The lack of regular auditing and analysis of these findings meant that at present the manager and the provider organisation did not have oversight of the service's operations and an effective way of knowing thatthe service people received was of a safe and good standard.

We found several examples of poor record keeping, omissions of information, documents that had been misfiled and entries made that were not accurate. We found the following examples: the reintroduction of medication in one person's care plan, dated March 2016 was not in sequential order as this entry appeared after later entries made in June 2016; two people's weekly weights were not documented as per their care plans; no DoLS documentation was seen in people's care records; references and records in two people's care records related to other residents; and incorrect date of birth on a person's MUST documentation. We highlighted these issues during our inspection. This meant that the service's records and data management systems needed to be strengthened to ensure that accurate information about people and staff was always readily available.

These issues were a breach of Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Overall we found that communication amongst suites and staff could be improved. We asked care staff if regular staff meetings were held and we asked to see the minutes of these meetings. The clinical nurse lead told us that they held weekly meetings with the lead nursing teams and we saw the minutes of those meetings. We were also told that general staff meetings on each suite were recently reinstated. We saw minutes of the staff meetings held on two of the suites.

We did not see any evidence that the service asked people or their relatives for their feedback about the service provided. We did see a record of four compliments received over the period October 2015 to August 2016. The clinical nurse specialist told us of future plans to have a residents' forum. We felt the service and provider did not demonstrate how it would capture people's opinions on the care they were currently receiving and how this could be improved upon or changed according to people's needs.

We found several examples where the service did not notify the CQC of incidents and accidents that occurred, such as safeguarding incidents and injuries relating to people living at the home. Failure to report these incidents was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009. For about half of those examples we did not see any record of the initial action that had been taken as a result of the incident nor was there any follow up action recorded. This meant the service had not demonstrated to us that it had appropriate oversight of the types of incidents that were taking place and what actions had been successful or not.

We found the lack of oversight by the provider organisation and management team on the overall care provision in relation to managing people's safety, ensuring staff were appropriately skilled and supported, offering on-going professional support and clinical supervision, and communicating regularly and effectivelymeant that they were not effectively managing the service to ensure the lives of people living at St Mark's were not adversely affected. This was a breach of Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.


The table below shows where regulations were not being met and we have asked the provider to send us a report that says what action they are going to take.We will check that this action is taken by the provider.

Regulated activity RegulationAccommodation for persons who require nursing or personal care

Treatment of disease, disorder or injury

Regulation 9 HSCA RA Regulations 2014 Person-centred care

Not all care plans were person centred and didn't reflect people's histories, interests and preferences.There was a lack of a structured activities programme to meet people's social needs.

People were not supported to maintain their independence by the physical environment they live in. The service had not adapted the premises to make it dementia friendly. Reg 9(1)



Regulation 11 HSCA RA Regulations 2014 Need for consent

There was no record that people or their representatives had consented to care.Staff had limited knowledge of MCA and DoLS. Reg 11(1)(2)(3)



Regulation 12 HSCA RA Regulations 2014 Safe care and treatment

• Not all staff had the right skills and competence to provide safe care

• People were not adequately protected from abuse because staff had not had training in safeguarding and policies and procedures gave incorrect safeguarding contacts

Action we have told the provider to take

This section is primarily information for the provider


• The provider did not adequately assess risks to the health and safety of people who used theservice or do all that was practicable to minimise the risks. Reg 12(1) and (2)(a)(b)



Regulation 13 HSCA RA Regulations 2014 Safeguarding service users from abuse and improper treatment

The registered provider did not have effective systems in place to protect people who used the service from abuse or improper treatment.Reg 13(1)



Regulation 18 HSCA RA Regulations 2014 Staffing

•Staff did not receive appropriate training or supervision to enable them to carry out their role effectively.Reg 18(2)(a)


The table below shows where regulations were not being met and we have taken enforcement action.



Regulation 17 HSCA RA Regulations 2014 Good governance

The registered provider had not established effective systems or processes to monitor and improve the quality of the service, assess and mitigate risks to health and safety or maintain accurate, complete and up to date records in respect of people who used the service.Reg 17(1)

The enforcement action we took:Warning notice

Enforcement actions

This section is primarily information for the provider

Documents

Marantomark Limited St Mark's Care Centre€¦ · 02 August 2016 03 August 2016 10 August 2016 Date of publication: 06 October 2016 Overall rating for this service Inadequate Is the