St Marks Residential Care Home

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.

St Marks 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 13 people using the service.

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

People and their relatives told us they had seen improvement in the care and support delivered. Whilst this inspection found some improvements had been made across the service, the providers approach continues to be reactive and not proactive in driving improvement.

Provider governance systems needed development to provide an accurate overview of the service and independently inform an ongoing plan for improvement and development. There was a lack of review and evaluation to complete the quality monitoring cycle and demonstrate the quality of the service was continually improving and developing to provide good outcomes for people.

Improvement was still needed in many areas, including staff recruitment and workforce planning, staff training and support, dementia care provision, accessible communication standards and communication, end of life care and the complaints process. We have made recommendations to the provider regarding all of these areas.

The environment was cleaner and safer. The service was undergoing a redecoration and refurbishment programme.

Positive relationships between people and staff had started to be established. There was positive feedback about the senior staff, including approachability and good communication.

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 inadequate for the second time (published 22 June 2022)

At this inspection we found some improvements had been made however the provider remained in breach of Regulations 9, 17 and 18. This service has been in Special Measures since April 2021.

Why we inspected

This inspection was carried out to see what improvement 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.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

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 continue to monitor information we receive about the service, which will help inform when we next inspect. The local authority quality monitoring teams continue to monitor the service to ensure the safety and welfare of people living at there.

The overall rating for this service is ‘Requires improvement’. However, the service remains in 'Special Measures'.

St Marks is a residential care home providing accommodation and personal care for up to 17 people aged 65 and over, in one adapted building. There were 13 people living in the service at the time of the inspection, who were vulnerable due to their age and frailty, including varying levels of dementia related needs.

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

The service was not well led. The provider had not done what they told us they were going to do to make and sustain improvement following the last inspection. There continued to be a failure to independently recognise and identify significant failings impacting on the quality and safety of service provision. Lessons had not been learned to minimise risk and drive improvement.

Thorough risk assessments were not carried out routinely to identify and mitigate risks in relation to people’s healthcare and support needs; safety concerns were not recognised, and practice placed people at risk of harm.

Management and staff were not following Government guidance and best practice infection prevention and control (IPC) guidance. Measures to limit the risk of cross infection continued to be neglected compromising people’s safety and welfare. Areas of the home were still not clean, and the provider was failing to have effective and additional cleaning schedules in place for frequently touched areas and deep cleaning.

Whilst some areas of the home environment had improved the appearance of other areas remained poor.

There were not enough staff to provide adequate supervision, nutritional support, infection prevention and control, stimulation and meaningful activity. This had a direct impact on people’s safety and welfare.

We continued to have concerns about the skills, experience and knowledge of staff. Improvements were needed in staff’s understanding of dementia care to enable them to support people in providing care that was effective and person centred. This included staff’s knowledge in managing high levels of anxiety, dysphagia and supporting people to have access to meaningful stimulus, tailored to their level of dementia/needs.

The culture within the home did not promote a holistic approach to people’s care that ensured their physical, mental and emotional needs were being met. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.

Staff were not supporting people in a planned, personalised and consistent way. There were lots of inconsistencies in how well people's care needs and preferences were recorded which meant there was a risk that people may not receive care in line with their needs and preferences.

Immediately following this inspection, we made safeguarding alerts to the local authority. The local authority safeguarding, and quality improvement teams continue to monitor the service through management support and regular visits to ensure the safety of people living at the service.

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 inadequate (published 4 August 2021). 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 the provider remained in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

The overall rating for the service remains inadequate based on the findings of this inspection.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified continued breaches in relation to Regulation 9, 12, 13, 17, 18 and a new breach of Regulation 14 at this inspection.

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 continue to monitor information we receive about the service. The local authority safeguarding, and quality improvement teams continue to monitor the service through management support and visits to ensure the safety and welfare of people living at the service.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

St Marks is a residential care home providing accommodation and personal care for up to 17 people aged 65 and over, in one adapted building. There were 15 people living in the service at the time of the inspection, who were vulnerable due to their age and frailty, including varying levels of dementia related needs.

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

We found the provider had not made sufficient and sustained improvement which means the service has deteriorated to a rating of inadequate. We continue to have concerns about the providers inconsistent governance and leadership resulting in the inability to achieve a rating of good. The providers approach continues to be reactive and not pro-active to driving improvement.

There continued to be a lack of recognition and understanding of risk, and lack of robust assessments and controls in place to protect people and keep them safe. We had concerns regarding infection control and fire safety and we are addressing this separately.

We continued to have concerns about the skills, experience and knowledge of staff. While they had received some element of training in dementia care, not all staff demonstrated an understanding of dementia and how this affected people in their day to day lives. Learning and development was not effectively managed to ensure staff had the right knowledge and skills to carry out their roles and provide the right care and support.

There were no clear plans of care and best practice approaches to supporting people with anxieties or rehabilitation needs. People were not provided with regular access to meaningful activities and stimulation, appropriate to their needs, to protect them from social isolation, and promote their wellbeing.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.

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 6 December 2019) and there were multiple breaches 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 enough improvement had not been made or sustained and there was a continued breach of regulations. The service is again inadequate.

Why we inspected

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. 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 Marks Residential Care Home on our website at www.cqc.org.uk

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to Regulation 9,12, 13, 17 and 18 at this inspection. 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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.

Rating at last inspection

St Marks Residential Care Home was rated Requires improvement at the last inspection which was published on 3 October 2018. This was a planned inspection based on the rating at the last inspection.

We have found evidence that the provider needs to make improvements. You can see what action we have asked the provider to take at the end of this full report.

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

St Marks Residential Care Home was taken out of special measures at the last inspection as they had made some improvement. At this inspection we found that some of the improvements which had previously been made had not been sustained.

Risks were not always identified or managed effectively to keep people safe. The physical environment was not well maintained and there was no methodical check of rooms and to ensure that issues were promptly identified and addressed. Infection control was not always effectively managed.

The service had several staffing vacancies including maintenance, activities and the deputy manager position. The registered manager told us that they had plans to address the shortfalls.There were enough care staff on duty, but some staff worked long hours which could impact on their ability to provide safe care. Checks were undertaken on staff prior to their recruitment but these were not sufficiently robust.

There were systems in place to safeguard people, but these were not fully understood or implemented consistently. We identified anomalies in how people were supported to manage their finances.

Staff received training but there were gaps in provision and in the oversight of the training staff had undertaken. Staff did not always recognise poor practice and we found shortfalls in the promotion of dignity and respect.

People told us that they enjoyed the food and received the support they needed with eating and drinking. We have made a recommendation about the oversight of what people consume, to ensure that shortfalls are promptly identified and escalated.

People received their medicines as prescribed and were supported to access healthcare when they needed it. People had good relationships with staff and told us that staff were kind and caring.

People told us that their independence was promoted. People had opportunities to give feedback on the care, but suggestions were not always responded to in a timely way.

Care plans were in place to direct staff on people’s needs and how they should be met but these were not always up to date or sufficiently detailed. People had some access to activities to promote their wellbeing.

Documentation was disorganised which presented some risks as issues could be missed or care not delivered effectively. There were some quality assurance systems in place, but they were not well developed. Where areas were identified as needing improvement the provider did not have an action plan with clear timescales for improvement.

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. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

We inspected again in November 2017 and found that improvements had not been made and there was a further concern in relation to recruitment. The service was rated ‘Inadequate’ and placed into special measures. We took immediate enforcement action to restrict admissions to the service. We also placed conditions on the provider’s registration requiring them to send us a report to inform us how people were being cared for in a safe environment by skilled staff.

During February and March 2018, we carried out a further unannounced inspection and we found that although some improvements had been made the provider was continuing to fail to meet the requirements of the regulations, commonly referred to as The Fundamental Standards of Quality and Safety and the service remained in special measures.

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

During this comprehensive inspection undertaken in August 2018 we found that improvements had been made.

This service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Marks Residential Care Home is an adapted building, located close to the town centre, sea front, GP surgery and public transport. The service provides accommodation and personal care for up to 17 older people. This includes people requiring support with medical and physical frailty, and people living with dementia. There were nine people living in the service when we inspected.

There was a registered manager in post, who was also a director of the company which owned the service. A registered manager is a person who has registered with the Care Quality Commission 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.

Since our last inspection of the service, while improvements had been made and we found no breaches of legal requirements, further improvements were still required. We viewed the appointment of an experienced person in care, as Nominated Individual, to be a very positive step, bringing stability, support and guidance to the management team. However, further improvements were still required. This is to ensure that quality assurance arrangements are continually robust and effective to drive, sustain and embed improvements to achieve continued compliance with regulatory requirements. We made a recommendation to support them in maintaining staffing levels, to ensure sufficient staff are consistently, and effectively deployed to meet people’s needs.

There were systems in place to safeguard people from abuse and staff had been recruited using safe recruitment practices. Staff were aware of their responsibilities and knew how to report concerns. However, further improvements were needed in the completion of records, to confirm the action staff had taken to ensure people’s safety and welfare.

Improvements had been made in infection control, décor and maintenance of the service, as part of an on-going refurbishment. This was providing people with a brighter, clean, well maintained, and safe, environment. We made a recommendation to support the provider in identifying where the layout of the service could be further improved to support people living with dementia.

Systems were in place to reduce / eliminate any risks associated with the person’s environment, supporting their care needs, or associated with promoting their independence. However further improvements were required around checking wear and tear on walking aids to ensure they are fit for purpose.

People were being supported by staff who received training and supervision to enable them to provide effective support in meeting their needs.

Staff were respectful and caring, supporting people to maintain their dignity and independence, including meeting other people living in the community. The range of activities to support people’s emotional and social wellbeing had significantly improved. People were being supported to continue with their hobbies / interests and where applicable, fulfil ambitions / wishes.

People, and where applicable, their relatives, were being involved in care planning to ensure the guidance given to staff met, and reflected their current needs.

People were supported to eat and drink enough as part of meeting their nutritional needs. They received their medicines as prescribed and were supported to access healthcare professionals. Staff were prompt in referring people to health services when required.

The culture within the service had improved. Views of the people living in the service, their relatives, and staff were being sought, listen to and used to drive improvements. Staff understood their responsibilities in relation to the Mental Capacity Act (MCA) 2005 and people’s consent was sought appropriately.

The managerial oversight in the service had significantly improved. Audit and quality assurance systems were in place to ensure that the quality of care was consistently assessed, monitored and improved. However, they had not identified all of the issues that we found during our inspection. This identified that further work was needed to ensure these systems continued to be embedded and sustained to drive continuous improvement.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures

People living at St Marks Residential Care Home receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service provides personal care for up to 17 older people, some people living with dementia. There were 14 people living at the service when we inspected.

At the inspection in November 2017 we identified continued breaches of legal requirements. There was poor leadership, management and provider oversight of the service. This led to people receiving poor care where risks to their health and welfare were not adequately protected. We took urgent enforcement action to mitigate the risks to people and restricted any new admissions to the service until we were satisfied improvements were made.

St Marks Residential Care Home is in Special Measures, which resulted from an Inadequate rating following a focused inspection undertaken in November 2017. The purpose of Special measures is to ensure providers found to be providing inadequate care significantly improve. We keep services placed into Special Measures 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 be providing inadequate care should have made significant improvements within this time frame.

You can read the reports from our previous inspections by selecting the ‘all reports’ link for St Marks Residential Care Home on our website at www.cqc.org.uk

Since the last inspection the provider has employed several different external consultants to help improve quality and safety. The local authority safeguarding and quality monitoring teams also continued to monitor the service through regular visits and support, mitigating the risks to people using the service and reviewing the provider’s improvement plan.

Despite this support the Commission continued to receive concerns from members of the public and professionals about the provider’s ineffective oversight of the service. This included concerns about the provider’s ability to improve the overall quality of the service. As a result there continued to be concerns about the ability of the provider to drive improvement and ensure people received safe, effective care. We therefore carried out this focused inspection to check progress against their improvement plan and check how those living in the service were being protected from the risk of potential harm. The inspection team inspected the service against two of the five questions we ask about services: is the service safe and well led.

There was a registered manager in post, who was also a Director of the company which owned the service (the registered provider). A registered manager is a person who has registered with the Care Quality Commission 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.

At this inspection we found although some improvements had been made, sufficient action had not been taken to mitigate the risk of harm and the provider remained in breach of the Regulations. The provider had delegated some of the improvement goals to consultants but had not retained effective oversight of their progress or responded promptly when they escalated concerns which needed the provider to take forward. This had led to disjointed work and poor communication about who was responsible for what, timescales and measures for improvement. Information received by the Commission included frustration from staff, professionals and others involved in the service about the Director/Registered Manager’s understanding of how the service needed to be run safely and effectively.

Assessments and controls had been introduced but they were not robust enough or monitored to ensure they were making improvements. For example risks associated with legionella, unsafe recruitment, fire safety and continued concerns around cleanliness and infection control.

Robust recruitment and employment systems were not in place to ensure appropriate and ongoing checks of employees. This put people at potential risk of being supported by staff whose identity, work permits, ability to work with vulnerable people, or qualifications could not be demonstrated by the provider. Where there were gaps in information no assessment of the risk that may pose had been explored. The provider was unable to demonstrate they could consistently ensure enough skilled staff can be deployed across the service to provide safe, personalised, quality care.

The overall governance structure in place relied on the Director/Registered Manager to make all decisions and be in control of all changes. Although some tasks were delegated to consultants and other staff the Director/Registered Manager had no effective oversight to ensure changes were embedded and carried through. The service remains Inadequate and the improvement plan put in place has not been effective at identifying and addressing the root causes effectively. We remain seriously concerned that the provider lacks the ability to drive the improvement needed and the service is continuing to fail people who live there.

The Commission is continuing to monitor this service. You can see what action we told the provider to take at the back of the full version of the report.’ Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work there.

No risks, concerns or significant improvement were identified in the remaining key questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection.

This service is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

St Marks Residential Care Home is an adapted building, located close to the town centre, GP surgery and public transport. The service provides personal care for up to 17 older people, some people living with dementia. There were 14 people living in the service when we inspected.

There was a registered manager in post, who was also a director of the company which owned the service. The registered manager was also registered to manage another care home for older people in Clacton which they owned. A registered manager is a person who has registered with the Care Quality Commission 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.

At this inspection we found that sufficient action had not been taken and the provider remained in breach of the Regulations. We found that some parts of the service presented risks to people and there was a lack of robust assessments and controls in place to protect people and keep them safe. The environment was not always well maintained and we continued to find concerns with cleanliness and infection control.

We continued to have concerns about the numbers of staff their knowledge and skills. Staff did not always demonstrate adequate knowledge about how to support people safely. For example there were risks associated with aspiration and choking, moving and handling, infection control, unstable wardrobes, window restrictors, storage of hazardous fluids and trip hazards.

The quality of the training staff received was not effective enough to demonstrate they were able and competent to meet the needs of the people using the service. The provider did not have systems in place to ensure they were up to date with best practice guidance and there was a lack of effective learning from safeguarding incidents to reduce the risks to people from reoccurring.

Improvements were needed in the medicines systems to ensure staff followed safe, person centred practice. The use and timing of ‘as and when required’ medicines, to ensure people received them safely in line with best practice, and their effectiveness monitored. This included staff being given clear guidance on the use of anti-anxiety medicines, to enable staff to demonstrate that non-medicines strategies had been tried first.

There were quality assurance systems in place but these were not robust or effective. They were not driving improvement and had not identified the issues that we found at the inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special 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 within this 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 varying the 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.

You can see what action we told the provider to take at the back of the full version of the report.

St Marks Residential Care Home provides personal care for up to 17 older people, some people living with dementia. There were 16 people living in the service when we inspected.

The service has a registered manager, who was also the provider. The manager was also registered to manage another care home for older people in Clacton. A registered manager is a person who has registered with the Care Quality Commission 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.

Improvements had been made in the staffing levels, however further work was needed. We have made a recommendation to support the provider in the deployment of staff. This is to ensure the service consistently has sufficient staff, with the right skills and knowledge to monitor and support people with complex needs.

Training was being provided for staff, but it did not always provide staff with the knowledge and skills to effectively carry out their role. The majority of training was provided by the registered manager. We identified concerns about staff’s understanding of current good practice and the ability to put training into practice. For example, where staff did not demonstrate knowledge of safe care and best practice in areas such as moving and handling, dementia care and infection control.

Further improvements were needed to support people with their mental and emotional needs by ensuring they had access to activities that provide mental stimulation. We recommended that the service explores the relevant guidance on best practice to enhance people’s wellbeing through meaningful occupation.

People complimented the quality of the food. However, we found people were not always supported to ensure that they had enough food and drinks to support their health needs. Records were incomplete and not assessed, we could not be assured that people had been given enough to eat and drink. Where people of low weight turned down food, or had a low appetite, this was not always being effectively managed. This put people at risk of losing, or not maintaining their weight.

Staff’s practice was not always shown to be caring or respectful. We saw some good interactions, and people told us they liked the staff. However, some support given focused on the provision of tasks and was not always person centred or individualised. It did not promote people’s wellbeing or ensure that people felt valued. We have made a recommendation to support staff in promoting dignity in care.

Improvements were seen in the development of people’s care plans. They were more individualised and reflected people’s wishes and preferences. However, some areas needed to be developed further, and in a way that reflected best practice. This is to ensure staff were being given clear guidance on meeting a person’s needs, that ensured their safety and wellbeing. For example supporting people’s mental health, and managing pain relief.

People were not always supported to have maximum choice and control of their lives and staff were not always supporting them in the least restrictive way possible.

People told us they felt safe, and there were systems in place to ensure people were being provided with safe care. However, further improvements were needed in the management of infection control and risk, to ensure staff were following safe practice, for example when assisting people to move safely.

The quality assurance systems had improved, however were still not robust enough to independently identify and address shortfalls as part of driving continuous improvements and embedding them in practice. Feedback we had received regarding the registered manager, described them as caring, but needed to be more proactive in instigating changes in a more timely manner.

During this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

There were 13 people living in the service when we inspected over three days. This was an unannounced inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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.

During our inspection we found multiple breaches of the health and Social Care Act 2008 (Regulated Activities) regulations 2014. The registered manager was also a director of St Mark’s Care Home Limited was clear that they would be taking action to make improvements. You can see what action we told the provider to take at the back of the full version of this report.

Staffing numbers were not assessed to reflect people’s dependency needs and impact of the layout of the building. As a result the service could not demonstrate that there were enough staff to ensure people were provided with care that was safe and promoted their independence and autonomy as far as possible.

Improvements were needed to ensure people’s environment and equipment, including bedroom furniture, provided by the service were maintained, safe and fit for purpose.

Staff understood their responsibilities to ensure people were kept safe and knew who to report their concerns to within the service. However, if the need occurred, not all were aware of the external agencies to contact. People were supported to keep safe when using the service and when out in the community, without taking away their independence. There were appropriate arrangements in place to safely support people with their prescribed medicines.

Staff received training to support people’s needs. However where we identified shortfalls in staff’s knowledge of supporting people with dementia, fire safety and providing clean and safe environment showed further work was needed. This was to ensure that staff put into practice what they had learnt, and where required given access to further training. We recommend the service explores available training and resources, based on best practice, in dementia care.

The service was aware of the changes to the law regarding the Deprivation of Liberty Safeguards (DoLS). Where needed appropriate referrals were made to external professionals. Further work was required to record the level of people’s capacity, and how they were supported to make daily decisions about their care and any restrictions made are lawful, and in the person’s best interest.

Improvements were needed to ensure consistency in the quality of food provided to meet people’s individual dietary needs, and preferences. We recommended that the service explores the relevant guidance on how to support people of poor appetite and weight to protect their health and wellbeing.

People and their visitors were complementary about the relaxed atmosphere of the service and welcoming, friendly staff.

Improvements were required to ensure people, or where appropriate, those acting on their behalf are consulted and encouraged to contribute to the planning of their care. This is to ensure that people received personalised care that was responsive to their needs and preferences.

People were supported to see, when needed, health and social care professionals to make sure they received appropriate and on-going care and treatment.

Improvements were needed to support people with their mental and emotional needs by ensuring they had access to activities that provide mental stimulation.

Staff had good relationships with people who used the service and their relatives. The majority of staff’s interactions with people were caring, respectful, supported people’s dignity and carried out in a respectful manner. However improvements were needed to ensure all interactions were carried out this way. We recommended that the service explores the relevant guidance on best practice for promoting people’s dignity and independence.

Quality assurances systems were in place but were not robust enough to pick up the shortfalls we identified. In addition the service was not up to date with best practice to ensure people were provided with good quality care, within a clean safe environment at all times.

A complaints procedure was in place to ensure people’s comments, concerns and complaints were listened to and addressed in a timely manner and used to improve the service.

Below is a summary of what we found. The summary is based on our conversations with the manager, two staff, three people who used the service, a visiting community nurse, a social worker and from looking at records. Where it was not possible to communicate with people who used the service we used our observations to gather information.

Is the service safe?

People were cared for in an environment that was safe, clean and hygienic. A visiting community nurse told us, "The home is very good, staff follow instructions and advice we give to them relating to people’s health care needs.”

Records contained detailed assessments of people's needs that had been carried out prior to them moving to the service. This ensured that the staff had the relevant skills and knowledge required to meet the individual's identified needs. Where people did not have the mental capacity to provide consent the provider complied with the requirements of the Mental Capacity Act 2005. Staff had received training in this area. The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Whilst no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

The provider had clear policies and procedures regarding medication, we saw that medication was stored, administered and disposed of in line with their policies and procedures. Staff received annual refresher training in administering medication. The provider carried out regular audits of medication.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. One person said, "I am happy here."

Is the service effective?

It was clear from what we saw, and from speaking with staff, that they understood people's care and support needs and that they knew the people well. A person who used the service told us, "The staff are polite, caring and they treat me with respect."

People's health and care needs were assessed with them, and they were involved in writing their plans of care, where they were unable to do so staff had spoken to their relatives or friends to gain their views. Specialist dietary needs had been identified in care plans where required.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. People's preferences, interests, religious and faith needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

Where people's care needs had changed appropriate referrals to the doctor, district nurse and dentist had been made and any recommendations had been acted on. The manager had regular contact with the relatives of people who used the service and health care professionals. Both of the health care professionals we spoke with were complimentary about the professionalism of the manager and the staff. They told us, "The home makes appropriate referrals to us."

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. Health care professionals who we spoke with told us, "The staff had kept them informed of people's changing health needs.

We saw the responses from the stakeholder survey. People had commented positively about the quality of the care provided to the people who lived in the home. The service had a quality assurance system in place. Records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuously improving.

The two staff we spoke with told us they were clear about their roles and responsibilities and they received excellent training, support and supervision from the manager. They told us that this enabled them to provide excellent care and support to people who used the service. We saw that staff had a good understanding of the aims of the service. This helped to ensure that people received a good quality service at all times.

We received positive comments from people living at the home, and from relatives that were visiting people who lived at the home.

We saw that staff spoke kindly to people living at the home and there was a calm and relaxed atmosphere.

A healthcare professional that we spoke with told us: “The staff are helpful and caring, they speak kindly and with respect to the people living at the home.”

Safeguarding procedures were in place to ensure people were safe, and the staff were supported through training to provide appropriate and safe care for people.

The home demonstrated they had enough qualified, skilled and experienced staff working to meet people’s needs.

We saw the home had an effective system to assess the quality of the service they provided.