Updated 15 August 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by an inspector.
Service and service type
St Marks is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. St Marks is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post. The registered manager worked at the service at least 1 day a week and was available by phone and email for the rest of the week. However, there was also an assistant manager with day-to-day responsibility for the running of the service.
Notice of inspection
This inspection was announced. We gave the service 24 hours’ notice of the inspection. This was because the service is small, and people are often out, and we wanted to be sure there would be people at home to speak with us.
What we did before the inspection
We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.
We reviewed the information we held about the service and the service provider. We looked at notifications we had received for this service. Notifications are information about important events the service is required to send us by law. We used all this information to plan our inspection.
During the inspection
We spent time observing how staff interacted with people to help us understand the experience of people living at the service. We spoke with the registered manager, the assistant manager and 4 staff members. We looked at a range of records relating to the home, which included records relating to health and safety, and the management of the home. We spoke with 3 people’s relatives and received correspondence from another person’s relative. We received correspondence from 3 health and social care professionals. We looked at 4 people’s care plans, audits, training data, 2 staff recruitment records, quality assurance records and meeting minutes. We have continued to seek clarification from the provider to validate the evidence found.