St Mark's Care Home Also known as St Mark's

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe, and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulations in relation to safe care and treatment, the management of people’s medicines, and recruitment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always maintain a proactive and positive culture of safety, characterised by openness and honesty. Staff did not always listen to concerns about safety and failed to investigate and report safety incidents. Lessons were not always learnt to continually identify and embed good practice.
We received mixed feedback from staff. One staff member told us, “Occasionally, if I say something about [people] eating that I am worried about, it has been taken almost like a personal attack.” Following the inspection, the provider told us they were aware of this incident and action was taken. Another staff member told us, “I made a complaint and the home manager’s behaviour towards me changed.” This did not demonstrate that staff were consistently encouraged or supported to raise concerns. It also did not show that staff felt empowered to report risks to people or their safety, nor that they were confident appropriate action would be taken to keep people safe.
We also reviewed staff meeting minutes and the registered manager told us there was a daily huddle with unit leads to discuss people’s care and treatment. Staff members informed us that they were provided with updates and information from their unit leads. Some staff also told us how they took learning from incidents. One staff member told us, “We discuss the incident and review what could be done differently or what safety measures to put in place.”
The provider shared evidence of how lessons were learnt and shared with staff. However, we found some incidents where records demonstrated that lessons were not always learnt and shared. We found that not all complaints had documented evidence of investigation or recorded learning outcomes, limiting opportunities for wider learning and continuous improvement.
For example, one complaint noted a person was given water in their cereal, was stood over until their medicine was taken, and a carer walked in during personal care without knocking. We found there was a lack of evidence this complaint was properly investigated and learning outcomes shared with all staff to ensure these examples of incidents were not repeated. The record noted ‘no further action’, and the root cause analysis did not provide an actual analysis of the cause of this to ensure this would not be repeated for other people.
The provider told us about the systems and processes currently in place to support staff which included weekly HR listening sessions, options for anonymous staff feedback and visits from the provider team. After our assessment the provider told us they had introduced an improved system to enable staff to reflect on lessons learnt and embed learning.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care.
People told us they did not always feel there were enough staff to ensure continuity of care. One person told us, “They send someone to help me at night and after that I don’t see anyone at all. I think it’s understaffed especially when they go on holiday. At weekends it’s the same, every day is the same as far as I’m concerned. They won’t agree that they’re short staffed.” Another person told us, “I don’t have enough help at night but they are far too busy. You obviously lose your dignity when you come into a place like this but they do their best.” Some staff also reported experiencing difficulty when requesting support from the partnership GP to visit the service and review people’s needs in person.
Some relatives told us they did not feel there was a collaborative, joined-up approach to safety that involved them, along with staff and other partners in their care. For example, one relative told us, “When it comes to the doctor, I have not been impressed at how he doesn't physically visit as much as he should, and a lot of his consultations are over the phone with the nurses.” This also meant that people and their relatives did not always feel involved in establishing care plans. The provider told us the registered manager held a meeting with the GP surgery to address concerns raised and to improve partnership working.
 

The provider did not always work well with people to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.
We found the provider maintained a safeguarding tracker to monitor the outcomes of referrals raised. Safeguarding training was generally up to date, and family members told us they felt confident their relatives were protected.
People told us, “I feel safe, and if not, I’d talk to the support staff.” The registered manager told us, “I am of the view it is everyone who needs to share concerns about [people], I had housekeeping sharing concerns as well.”
While many incidents had been referred to the local safeguarding authority, as needed, there were incidents which were not consistently shared without delay. For example, we found one person was subject to a safeguarding concern. The incident report indicated this was not investigated without delay, and a safeguarding referral was not raised by the registered manager. This showed a breakdown in the oversight of safeguarding and failure to recognise the severity of some incidents.
People’s views of feeling safe was mixed. One person told us, “The thing that does worry me, is that one [person] who has designs on me and it’s very worrying. [Person] turned on me yesterday and [person] turns up in my room. They separate [person] from me in the dining room. I tend to stay in my room longer than I would like as I want to feel safe.”
 

The provider did not work well with people to understand and manage risks.
We found high risk conditions were not always captured in people’s care plans to ensure they were supported safely and effectively. For example, 3 people had epilepsy. But 2 people did not have clear and detailed care plans to support them with such a condition. The records lacked information regarding types of seizures, as well as any signs and triggers to look out for, to ensure staff were able to respond in a timely manner and provide medical support. This meant people were at risk of harm because staff did not have vital information on how to manage epilepsy. After the assessment the provider told us people’s care plans had been reviewed, and staff were in the process of undertaking epilepsy training
Another person was assessed as requiring repositioning by a slide sheet. However, we found they were repositioned by hand according to their care records. This meant the person was at risk of harm or injury because staff did not always support them in line with their assessed needs.
The registered manager did not ensure risks relating to paraffin-based creams were monitored and managed effectively. For example, one person was using medical oxygen, and they had 3 different creams prescribed that could pose a fire risk. The provider’s general risk assessment for paraffin-based creams used in the home noted that these types of creams should not be used if someone is on medical oxygen. We raised this with the registered manager. We were informed on the second day of the visit that the creams were changed to water-based ones. The individual's flammable cream risk assessment for this person was completed after the first day of our visit. This meant the person was put at risk of harm, and the change was prompted by our visit rather than effective oversight of the risk related to oxygen usage. A number of risk assessments for paraffin-based creams were not in place and were completed after our visit.
 

The provider did not always detect and control potential risks in the care environment. They did not always ensure that equipment, facilities, and technology supported the delivery of safe care.
We found some equipment within the home, such as chair scales, that were not calibrated by their due dates, ensuring they were always safe and accurate for people to use. The provider took action to have this calibrated after we discussed this feedback. This also meant that quality assurance systems had failed to identify and take action to ensure that this equipment was maintained, effective, and fit for use.
Furthermore, we also found the fire risk assessment was overdue at the time of the visit. The provider did not evidence that they completed the risk assessment without delay, especially given the large refurbishment works being carried out within the building. This did not provide assurance all risks with building and fire had been identified and managed to ensure people were protected from harm.

The provider deployed sufficient staff to meet people’s needs, but did not always ensure all staff were appropriately recruited, trained and had their competency assessed before delivering care and treatment to people.
The registered manager did not operate effective and robust recruitment procedures to ensure they employed suitable staff. We found discrepancies with gathering information of full employment history and unexplained gaps, evidence from previous employments related to health and social care regarding staff conduct and verifying the reasons for leaving. We requested further evidence from the provider to address the missing information; however, the provider was unable to evidence all discrepancies were accounted for before staff provided care and treatment to people.
We noted that gaps in employment were verified after the CQC visit. The registered manager did not ensure all required recruitment information was obtained before staff started work. This meant people were at risk of being supported by unsuitable staff.
Some staff members told us they did not feel the induction was robust, which impacted their ability to complete tasks. We reviewed staff training and competency assessments. We found a lack of evidence of training for specific topics, including the administration of rectal Diazepam.
We reviewed staff training and competency assessments. At present, competency assessments were carried out by senior care staff and Nurses. However, the provider did not clearly evidence all the topics covered in their assessor training, ensuring that assessors knew the law and current guidance for areas of assessment. This approach raised concerns about the accuracy and reliability of competency checks.
We reviewed the staff training matrix and found there was a lack of evidence of specific training and competency completed for specific topics including catheter care, administration of rectal diazepam and percutaneous endoscopic gastrostomy (PEG). A PEG is a procedure to insert a feeding tube through the skin and into the stomach, allowing liquid food, drinks, and medications to be delivered directly. This is despite some people within the service having a catheter or PEG. One person required support from trained nurses for suctioning to clear excess secretions. However, the provider did not evidence that this training was completed, regularly refreshed, and competency assessed. This did not demonstrate people were safely supported by trained and skilled staff.
During our review of daily care records, we identified instances where staff performed clinical tasks without documented evidence of appropriate training or competence. For instance, one person using the service had a catheter in place, and staff were supporting them with catheter bag changes. However, records indicated that some nursing staff had not received competency assessments for catheter or PEG care. This potentially posed a risk of people receiving poor care. The provider sent us staff rotas which demonstrated a consistent level of care and nursing staff were deployed. However, some people felt that there were not enough staff in the service. One person told us, “Not enough, I feel sorry for them sometimes, and I know the carers have been frustrated by it. Weekends are like the Marie Celeste (ghost ship). My only criticism is that there are not enough staff.” Furthermore, one staff member told us, “At nighttime, there is 1 nurse and 1 carer. I don’t know how they are surviving; it is horrible.”
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and promptly shared concerns with the appropriate agencies.
We reviewed the provider’s audits around infection prevention and control. We found that staff were provided with appropriate personal protective equipment (PPE) to minimise the risk of infection spreading. We also observed that three people were supported to isolate to manage the risk of infection within their homes. We observed staff utilised PPE when supporting people in isolation.
 

The provider did not ensure that medicines and treatments were safe and met people’s needs, capacities, and preferences. People were not involved in planning.
There were 4 people receiving medicines covertly. Covert administration of medication is the practice of administering medicines to a person in a disguised format without their knowledge or consent. There were no personalised care plans outlining how to manage medicines overtly and covertly, including the need for covert administration for each prescribed medicine and the duration for which these care plans should be used. Covert administration must be the least restrictive option after trying all other options. There was no evidence to show this practice was carried out by staff administering medicines. The staff had contacted pharmacists for confirmation and advice about the safety of giving medicines covertly mixed with certain foods or drinks. However, this was done after our site visit.
We found that as-needed (PRN) protocols were not always detailed, completed consistently, and person-centred. It was not always clear if people could express themselves or what specific non-verbal cues to look out for to ensure timely treatment. For example, one person had a sedative prescribed to support emotional well-being. However, it only noted symptoms such as ‘agitation, anxiety, distress behaviour’ rather than a clear and detailed description of support needed. The person received this medicine in September, but it was not recorded on the Medicines Administration Record (MAR) sheet. Another person had a medicine to manage pain, but the protocol had limited details, such as noting ‘regionalised pain; pain and discomfort’, which did not include any clear individual details for this person. This meant people’s treatment was not always guided by their individual needs to ensure most effective approach.
We found that 1 person was administered an ‘as-needed’ (PRN) sedative medicine without evidence that they were supported in a person-centred way. The care plan for emotional support described some techniques to support the person if they were upset or distressed. However, there was no evidence that the person was supported according to their individual needs before administration of this medicine. Another person also had a sedative because they were ‘agitated’. The daily notes did not evidence how staff provided support and reassurance before using the sedative as a last resort. This meant people were not always supported in the least restrictive way.