Archived: St Mark's Care Centre

St Mark's Care Centre is a care home which was purpose built and registered with CQC in July 2015. It is located near the centre of Sale in Trafford, South Manchester. The home is registered with CQC to provide nursing care for 62 people living with dementia, acquired brain injury or enduring mental health needs. The home has five units which are called Walton, Walkden, Woodhey's, Worthington and Ashton.

Due to enforcement action taken following our October 2017, the provider has not been able to admit any new service users to St Mark’s Care Centre. This meant at the time of this inspection, there were 31 people living at the home and there were three units in operation; Walton, Walkden and Worthington.

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

At our last inspection in October 2017, the home was rated as ‘Inadequate’ overall and in the key questions, safe, effective, responsive and well-led. Caring was rated as ‘Requires improvement’. We identified the provider was in breach of the following regulations; Regulation 9, person-centred care; Regulation 12, safe care and treatment; Regulation 13, safeguarding service users from abuse and improper treatment; Regulation 14, meeting nutrition and hydration needs; Regulation 16, receiving and acting on complaints; Regulation 17, good governance and Regulation 18, staffing. As a result of our findings, St Mark’s Care Centre remained in special measures.

Other enforcement action is on-going and the outcome of this will be added to the report after any representations and appeals have been concluded.

At this inspection, we identified continued breaches of the regulations and the overall rating for St Mark’s Care Centre is inadequate. Special measures remains in place and we will continue to monitor the service closely and will expect to see continuing and sustained improvement.

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, it 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.

At the time of our inspection, there was a registered manager in post who had started at St Mark’s Care Centre in December 2017 and commenced the process of registering with CQC. Their registration was completed 13 April 2018. A registered manager is a person who has registered with 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.

At this inspection, we identified failures in respect of the delivery of safe care and treatment and how risks to people who used the service were identified and mitigated. In particular, risks associated with the management of people’s dietary needs and pressure areas.

We found the provider and management team could demonstrate greater transparency in the reporting of events and incidents. However, we identified inconsistencies across the three units in regards to the recognition of safeguarding matters and identified a number of safeguarding referrals on Walton unit that should have been made to the local authority.

We found there was ambiguity regarding people’s care records and identified concerns regarding risk management. We found the most current risk assessments and up to date care plans were not in people’s care files but stored electronically and all the care staff did not have access to this information. This meant care staff did not have access to the identified risk in order to mitigate the risks and provide safe care.

We expressed concerns with the current quality and safety of the electronic method of care planning. At the time of the inspection, all the care plans, risks assessments and other service user documentation were written into word and excel files and stored on the local network drive. Concerns with this method include overwriting errors, duplications of files, and the lack of security in relation to care plan reviews, as anyone could write that a named nurse had reviewed a care plan with no electronic signature or secure method to determine this.

Appropriate recruitment checks were undertaken prior to staff commencing in post. We saw the use of agency staff had significantly reduced since our last inspection and recruitment was on-going to address the homes agency use.

Medicines were not always managed safely. Issues were identified regarding documentation and the consultation of a pharmacist when covert medicines were being given.

We found the provider was not always working within the principles of the Mental Capacity Act (2005). This was because best interest decisions were not evident for the use of restrictive practices such as lap belts and bed rails. Although we acknowledge these had been implemented to mitigate risks, we found best interest meetings had not been convened to determine that the use of these measures were in people’s best interest in accordance with the Mental Capacity Act 2005.

Since our last inspection, we saw that all the locks had been removed from communal doors and there was an emphasis in care plans regarding supportive measures to meet people’s needs. We saw this had translated to practice since implementation as there had been no recorded use of restraint on the accident and incident forms since these changes had been made.

We saw daily meetings had been introduced to support communication and management oversight of occurrences and support required within the home.

The induction had vastly improved. Staff received an induction to the service that was aligned with the care certificate and undertook shadow shifts with an experienced member of the staff team. The staff member continued to mentor them through the induction to support them within the role. Training had significantly improved. This included, staff competency assessments and there was an on-going rolling programme of on the spot training and supervision to address any shortfalls in practice.

The meal time experience had improved but we observed insufficient time was maintained between meals which we raised with the provider on the day of our inspection.

Relatives were extremely positive about the care provided and felt consulted about the care their family member required. We observed positive interactions between staff and people throughout the inspection visits across all the units. We did inform the registered manager of one instance observed of staff not maintaining a person’s dignity. This was because staff had transferred a person in a wheelchair without footplates which resulted in their feet being dragged across the floor in an unsafe and undignified manner. The registered manager gave assurance this would be addressed straight away and all wheelchairs without footplates would be removed from use.

We observed staff providing people with choices during the inspection and promoting people’s independence where able. People were engaged in daily activities and there was a singer that performed at the home on the second day of our inspection that was observably enjoyed by all those that attended.

The complaints process had significantly improved as there was now a process in place that logged complaints and a clear audit trail could be seen of actions taken. Relatives spoken with confirmed they were aware of the complaints process and that any complaints they had made had been resolved to their satisfaction.

The registered manager and care consultancy firm were not always coordinated in their approach to determine that there was a cohesive approach to achieving regulatory compliance. There were two action plans in progress at the time of the inspection and the registered manager did not have access to documents requested to determine progress against one of the action plans to demonstrate they had oversight.

CQC had not been notified of these events by the registered manager or provider which is there statutory duty. A suspension on admissions was imposed by Trafford CCG and Trafford council on 29 September 2017 for a period of eight weeks. This meant Trafford CCG and Trafford council would not be commissioning the service during this timeframe. Trafford CCG and Trafford council also shared this action with other commissioning authorities.

St Mark's Care Centre is a care home which was purpose built and registered with CQC in July 2015. It is located near the centre of Sale in Trafford, South Manchester. The home is registered with CQC to provide nursing care for 62 people living with dementia, acquired brain injury or enduring mental health needs. The home has five units which are referred to internally as suites. The suites are called Walton, Walkden, Woodhey’s, Worthington and Ashton. At the time of inspection, Ashton was not open to admissions.

At the time of our first inspection visit there were 50 people living at the home but there was an expected death whilst we were undertaking the inspection which meant there were 49 people by our last visit.

The home’s first inspection following registration was August 2016. At that inspection, we found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to person-centred care, seeking consent, safe care and treatment, safeguarding service users from abuse and improper treatment, governance and staffing. The home was rated as inadequate overall and placed in special measures. We served a warning notice for regulation 17; good governance.

At our second inspection in February 2017, we found there had been some improvements but there still remained four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to person-centred care, seeking consent, safeguarding service users from abuse and improper treatment. The service remained in special measures as the key line of enquiry, well-led, remained inadequate.

At this inspection, we found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to person-centred care, safe-care and treatment, safeguarding service users from abuse and improper treatment (two parts), meeting people’s nutrition and hydration needs, complaints, good governance and staffing (two parts).

We made a decision under Section 31 of the Health and Social Care Act 2008, to impose a condition to the registration as a service provider in respect of the regulated activity; Accommodation for persons who require nursing or personal care and Treatment of disease, disorder and injury at St Mark’s Care Centre. We imposed the following condition; the registered provider must not admit any new service users to St Mark’s Care Centre, Delaunay’s Road, Sale, M33 6RX.

The Notice of Decision was served on 23 October 2017. We are still considering further enforcement options in relation to this service.

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

At the time of the 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. The registered manager was in the process of leaving the service and there was an incoming manager who at the time of our inspection had commenced the process to register with CQC.

Following the inspection, there was a significant change in leadership arrangements at St Marks Care Centre. The registered manager and area manager resigned and the provider brought in a registered manager from a home in their portfolio that is currently rated as good with CQC. The provider is currently working alongside Trafford local authority and Trafford CCG to recruit a suitable manager and area manager with the required skills and competency to make the changes required ensuring that the regulatory requirements are met.

At this inspection, we found people were not safe as they were not protected from the risk of aspiration or choking. People assessed as having an 'unsafe swallow' were given foods that were not in keeping with their assessed needs and could have exposed people to the significant risk of harm.

We found ineffective systems in place to safeguard people from abuse and improper treatment. Prior to the inspection, we received information from Trafford safeguarding team that there was a low incidence of safeguarding reporting at St Mark’s Care Centre and when safeguarding referrals were made, they were indicative of high incidence of harm. During our inspection, we identified six safeguarding concerns that met the safeguarding threshold and had not been reported to Trafford safeguarding team or CQC. We made the safeguarding referrals following our inspection.

We spoke with people’s relatives and visitors regarding the staffing at St Mark’s Care Centre. We received positive feedback regarding the permanent staff at St Mark’s Care Centre but concerns were expressed regarding the high use of agency staff at the service. Whilst a formal dependency tool was used to determine staffing numbers, we observed there was a high use of agency staff which was not conducive to meeting people’s individual needs. We found the use of agency staff was having a detrimental impact on the quality of care people received.

Staff recruitment was robust, with appropriate checks carried out before staff began working at the home.

Medicines were managed safely. There were PRN protocols and covert administration records in place that had been agreed with people’s GP and pharmacy. However, following the inspection, we received information of concern regarding the management of covert medicines and this will be followed up at our next inspection.

We found the management were unable to evidence the induction training staff had received. The system to ensure staff competence following training had also not been followed which meant staff were working without the required competence and skills to fulfil the duties of their role. Staff had not been appropriately supported by the management and leadership as they had not received consistent support through supervision and appraisal.

The service was not complying with the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) as least restrictive interventions were not followed to support people to receive the care and treatment they required. DoLS applications were not made timely and the restrictions imposed were in excess of what would be expected in this type of care setting.

People’s relatives and visitors expressed concerns regarding the quality of the food people received and we observed there was no choice at mealtimes. Dietician guidance was not readily accessible when required and we found a referral had not been made timely when a person had been identified with significant weight loss.

People’s relatives and visitors spoke highly of the care received by permanent staff. However, they did not feel agency staff were responsive to their relatives needs and we observed practice that was not conducive to nurturing a calm environment.

People did not receive person-centred care that was responsive to their needs.

We found there was no effective system in place to manage complaints. People’s relatives and visitors expressed concerns and complaints but these had not been recorded or acted upon.

We identified significant shortfalls in the care provided to people at St Mark’s Care Centre. This was linked to ineffective governance arrangements and leadership which resulted in the management not having oversight regarding the quality and safety of care received by people living at the home.

This inspection took place on 1 and 2 February 2017. The first day was unannounced which meant the service did not know we were coming in advance. The second day was by arrangement.

At the previous inspection in August 2016 we had rated the service as inadequate in three areas and overall, and found breaches of six regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We placed the service in special measures, and issued a Warning Notice in respect of the breach relating to good governance. We also requested the provider to undertake not to admit new people into the home until the service became compliant with regulations. At this inspection in February 2017 we checked to see whether the service was now compliant with regulations. Our detailed findings are set out in the main part of this report.

There was a registered manager who had been in post since the service opened in July 2015.

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.

Most but not all staff had received recent training in safeguarding. We found that two allegations of abuse had been made. Disciplinary action had been taken but the incidents had not been reported to the local authority. This was a breach of the regulation relating to safeguarding.

Issues identified at the last inspection relating to the safety of the premises had been dealt with.

Staffing levels were adequate, with a high number of staff present on some units providing one to one care. However, there was a high reliance on agency staff. Some agency staff worked regularly at St Mark's. Efforts were being made to recruit more permanent staff. Recruitment procedures helped ensure that only suitable staff were employed.

Medicines were managed safely. The room temperature was high in one of the clinics were medicines were stored, but this was reduced during our visit.

The building was kept clean, and was well maintained. There were suitable precautions against fire, and emergency evacuation plans in place.

The consent form in use allowed relatives to consent to the care being received, which was not in accordance with the Mental Capacity Act 2005.

The service used mental capacity assessments correctly and had made appropriate applications under the Deprivation of Liberty Safeguards.

Training had improved since the last inspection. There was a programme of regular staff supervision.

There was a new supplier of food. People’s views differed as to how good the food was. We have made a recommendation about monitoring and improving food quality.

People’s weight and diet were monitored.

Some efforts had been made to improve the environment for people living with dementia, but there was scope for development.

People and their relatives spoke favourably of the quality of care at St Mark's. We witnessed good interactions. We also saw an example where agency staff ignored the people they were sitting with, which was a breach of the regulation relating to person-centred care.

Advocates were made available if people needed them.

St Mark's staff had limited training to provide care at the end of life.

Activities were led by an activities organiser. There was a mixture of group activities and one to one activities.

Care plans were created and stored on a computer system. They were detailed and thorough and easily accessible.

Complaints were recorded, responded to and analysed.

Relatives expressed approval of the registered manager, and staff morale was good although there was a high level of staff sickness.

Three safeguarding incidents which should have been reported to us had not been. This was a breach of the relevant regulation.

There had been a residents’ and relatives’ meeting but it had not been well attended.

A new system of quality monitoring had been introduced and we saw this was working effectively.

The local authority had been closely involved. Audits were thorough and frequent.

We found considerable improvements had been made since the last inspection, even though further improvement was still needed. We found a breach of the regulation relating to oversight and governance.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the end of the full version of the report.

Following the last inspection we found the service to be inadequate overall, and placed the service in special measures. Although the overall rating is now “requires improvement”, because there is one inadequate rating in one key question, special measures remain in place. We will continue to monitor the service closely and will expect to see continuing and sustained improvement.

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, it 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.

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 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.

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 risks which 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 restraints were 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 washing hands 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 Deprivation of 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 unaware of 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 during our 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 were unsure 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. We noted 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