We inspected St Mark’s Court on 24 October 2018. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting.

St Marks Court is a ‘care home’. People in care homes receive accommodation, nursing and 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 Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom have dementia. At the time of this inspection 50 people used the service.

We last inspected the service in September 2017 and found the service was not meeting our expectations. We rated St Mark’s Court as Requires improvement overall and in four domains. We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which related to safe care and treatment and good governance.

We found that the provider was failing to submit notifications, which is an offence and we issued a fixed penalty notice. The provider paid the £1250 fine and has subsequently sent in notifications.

The service has not had a registered manager since June 2017. 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. Over the last year the provider had recruited three managers and one person had applied to be the registered manager but left the service before the process was completed. At the beginning of September 2018, a new manager had started working at the service.

At the last inspection we highlighted concerns around how people were supported with their mobility. Staff needed to ensure that they adopted the correct moving and handling techniques. Moving and handling equipment needed to be appropriate for each individual and stored appropriately. Accidents and incidents were monitored but we found improvements were needed with how the information was analysed and used to assess risks of falls and injury. We found that the provider was changing the systems they used for monitoring the service and in the transition period the systems in place had not picked up the issues we identified.

At this inspection we found that although the provider had been working to resolve these issues and improvements had been made, the instability in the management had led to a continuation of issues.

We found that the provider was introducing new training programmes but not all staff were up to date with mandatory training. New staff had not received moving and handling training, the catering staff had not renewed food hygiene level two awards and the provider needed to ensure there were sufficient qualified first aiders to cover 24 hours every day. Staff had not completed regular supervision sessions but the new manager was re-introducing these.

There were not enough staff on the unit for people living with dementia during the mealtimes to ensure people ate sufficient food. Also, staff on this unit did not fully recognise when people were at risk of malnutrition or take proactive measures to encourage people to consume sufficient nutritious foods and maintain their weight. Catering staff were not always alerted to people’s dietary needs and had not been support to understand how to create foods that were suitable for people at risk of losing weight.

The regional manager discussed how they had recently reviewed staffing levels and these were to be increased both during the day and overnight. They were in the process of recruiting staff to fill these newly created vacancies. Recruitment and selection procedures were in place and appropriate checks had been undertaken

We inspected St Mark’s Court on 3 August 2017. This was an unannounced inspection which meant that the staff and registered provider did not know that we would be visiting. We also visited the service on 4 September 2017, to seek information about the actions the new manager had been taking since taking up post two weeks earlier.

We last inspected the service on 6 May 2015 and found the service was meeting our expectations. We rated St Mark’s Court as ‘Good’ overall and all in five domains.

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom have dementia. At the time of this inspection 42 people were in receipt of care from the service.

The home has not had a registered manager since June 2017. 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 provider had recruited a person to be the registered manager and they started working at the service in the middle of August 2017.

During our observations of care within the service, we identified concerns related to how people were supported with their mobility. Staff needed to ensure that they adopted the correct moving and handling techniques. Moving and handling equipment needed to be appropriate for each individual and stored appropriately. We raised concerns around specific practices and the quality manager informed us they would review this and submit safeguarding alerts immediately. We observed that equipment such as slings were stored in a pile on the floor, which was unhygienic. Also equipment such as wheelchairs were identified by numbers rather than the person’s name so it was difficult for staff to find the item for the individual who had been assessed to use it.

Accidents and incidents were monitored but we found improvements were needed around how the information was analysed and used to assess risks of falls and injury. We found that the provider was changing the systems they used for monitoring the service and in the transition period the systems in place had not picked up the issues we identified.

Safeguarding and whistleblowing procedures were in place. Staff reported concerns but needed to take ownership for reporting matters to the local safeguarding team. They also needed to ensure recommendations made by safeguarding teams were implemented, such as making sure people were supported to change their position in chairs regularly throughout the day.

A complaints process was in place and any concerns were investigated by the regional manager or the quality compliance team. However people told us that at times when they raised issues they received no feedback and action was not taken to rectify their concerns.

People’s care records were cumbersome, extremely difficult to navigate and we often found it difficult to get a sense of the person’s needs. The lack of a detailed written assessment had contributed to the difficulties around developing the care records as an effective working tool. Staff needed to improve the accuracy of their recording when monitoring peoples' fluid intake.

People told us they felt the care staff did a good job. People’s rights under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS) were protected.

We found a range of activities were available on the ground floor which people from elsewhere in the service accessed. When we visited a pet therapy session was taking place with a pony and the staff had been breeding chickens. The chickens were kept in the bar area of the home, which was away from the main areas of the service. They were reaching maturity so needed to be moved outside and despite staff best efforts, such as ensur

We inspected St Marks Court on 6 May 2015 and the visit was unannounced. We last inspected the service in November 2014. At that inspection, we found breaches of legal requirements in five areas; consent to care and treatment, record keeping, staffing, supporting staff and assessing and monitoring the quality of service provided. We asked the provider to take action to make improvements and they told us they would be fully compliant with the regulations by 30 April 2015. On this visit we found improvements had been made in all of the regulations that had been previously breached and the registered provider was now meeting current regulations.

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care and support is provided for older people, some of whom have a dementia related condition. At the time of the inspection there were 33 people living at the service.

The service had a registered manager who had been in post since December 2014. 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.

People using the service told us they were well cared for and felt safe at the home and with the staff who provided their care and support. The home was clean, tidy, well maintained and no unpleasant odours were evident in any part of the home.

Staffing levels were sufficient to meet people’s needs and employment procedures ensured that appropriate recruitment checks were undertaken to determine the suitability of individuals to work with vulnerable adults.

Improvements had been made to the management of medicines. Medicines records were accurate and complete, and medicines were managed safely. People’s medicines were stored securely.

Staff recruitment procedures ensured that appropriate recruitment checks were carried out to determine the suitability of individuals to work with vulnerable adults. Security checks had been made with the Disclosure and Barring Service (DBS). DBS checks help employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

Staff members had a good understanding of safeguarding adult’s procedures and knew how to report concerns. A whistleblowing policy and information was available for staff to report any risks or concerns about practice in confidence to the provider.

Staff were attentive when assisting people and responded promptly to requests for assistance or help. Appropriate risk assessments were in place to ensure risks were assessed and appropriate care and support was identified.

Accidents and incidents which occurred at the home were reviewed and analysed regularly to identify possible trends and to prevent reoccurrences. Duty managers were available out of hours for advice and in the event of an emergency.

People received care from staff who were provided with effective training to ensure they had the necessary skills and knowledge to effectively meet their needs. Staff received regular supervisions and annual appraisals were carried out. All new staff received appropriate induction training and were supported in their professional development.

Improvements had been made in relation to of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Detailed information was available for staff. The requirements of MCA were followed and DoLS were appropriately applied to make sure people were not restricted unnecessarily, unless it was in their best interest.

People were supported to make sure they had enough to eat and drink and their nutritional needs were met to ensure they stayed healthy. They told us enjoyed the food prepared at the home and had a choice about what they ate.

People were supported to have access to healthcare services and referrals had been made to health professionals for advice and guidance. The home provided a suitable environment and was adapted to meet the needs of people living with a dementia related condition.

People spoke positively about living at the home and told us staff treated them well. We observed warm, kind and caring interactions between staff and people. Staff were patient, unhurried and took time to explain things to people clearly. Staff acted in a professional and friendly manner and treated people with dignity and respect. We observed staff supporting people and promoting their dignity. Staff regularly checked on people to see if they needed support or assistance.

People were encouraged by staff to be independent, and maintain hobbies and interests that were important to them. People were supported and encouraged by staff to access their communities. A comprehensive activities and entertainment programme was available. This helped prevent people becoming socially isolated and provided interest and stimulation. People’s relatives were involved in the care and support of their family member. Care records confirmed their involvement in care planning and reviews.

We saw people were asked for their permission before care and support was delivered and they were offered choices. Meetings were held for people using the home and their relatives. Surveys were undertaken and people’s feedback was acted upon.

A complaints policy and procedure was in place. People and their relatives told us they felt able to raise any issues or concerns. Complaints received by the service were dealt with effectively and the service had recently received a number of compliments. Advocacy information was accessible to people and their relatives.

Care plans were regularly reviewed and evaluated. They contained up to date and accurate information on people’s needs and risks associated with their care. Health and social care professionals were involved in the review process where applicable.

The service had a registered manager who spoke positively and enthusiastically about their role. Staff told us noticeable improvements had been made which had resulted in a positive impact in the quality of service provided. Staff also told us the registered manager was supportive and approachable.

Management regularly checked and audited the quality of service provided and made sure people were satisfied with the service, care and support they received.

Up to date and accurate records were kept of equipment testing. Other equipment and systems were also subject to checks by independent assessors or companies.

Care staff we spoke with told us the management team was approachable and supportive. We received positive feedback from people, their relatives and staff about the management team and how the service was managed and run.

Staff meetings were held regularly. Staff were asked their opinions in an annual satisfaction survey and were satisfied and very positive about their work.

We found action had been taken to improve the personal records of people who used the service. People’s needs were thoroughly assessed and they were involved in decisions about their care planning. Care plans and corresponding records were kept up to date to make sure they reflected the care and treatment that people received.

We spoke with four people who lived in the home, they told us their choices and preferences were respected. One person said, “I like to and sit in the garden on a nice day”. Another person said, “I choose every day what I’d like to eat, the staff come and ask me each day what I’d like from the menu. It’s important to enjoy your food, and it’s really good here”.

People said that the service supported them to maintain their independence, one person said, “I like to be independent, I can still do things for myself, so why wouldn’t I? When I have a bath staff help me to the bathroom, and they come and get me when I ask, but I do the rest myself”.

All of the people we spoke with told us they were happy with the care which was provided to them. One person told us, “It suits me down to the ground here”. Another person said, “I’ve lived in another home before, but this one is the best”.

People we talked with spoke highly of the staff team within the home. One person said, “The staff are wonderful”. Another person, when talking about the staff said, “The lasses are smashing, I couldn’t fault them”.

This inspection took place on 6 and 10 November 2014 and was unannounced. This meant the staff and the provider did not know we would be visiting. We last inspected St Marks Court on 17 and 21 July 2014.

At the last inspection we found the provider was not meeting all the regulations we inspected. We found people’s care and treatment was not always planned in a way that ensured their safety and welfare; the service had not always taken steps to provide care in an environment that was adequately maintained; there were not enough qualified, skilled and experienced staff to meet people’s needs; staff did not always receive appropriate training and suitable appraisal and supervision arrangements were not fully in place; the systems the provider had in place to monitor the quality of service people received, were not effective, or undertaken on a regular basis. An action plan was received from the provider which stated they would meet the legal requirements by 30 September 2014. At this inspection we found improvements had not been made in relation to three of the five breaches and there were two further breaches of legal requirements.

St Marks Court is a care home which provides nursing and residential care for up to 60 people. Care is primarily provided for older people, some of whom are living with dementia. At the time of our inspection there were 45 people living at the home. Accommodation at the home is arranged over three floors. The ground and first floor being dedicated to providing accommodation and care for people requiring general nursing needs and residential care. The second floor is for people living with dementia.

The home did not have a registered manager, as the manager in post was awaiting the outcome of her application for her CQC registration. Following our inspection, the manager received her CQC registration. 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 majority of people at the home, their friends and relatives told us there were not enough staff on duty at important times. Seven of the ten care staff we spoke to told us they felt they were insufficient staff on duty at all times. They said this had an effect on the time they were able to spend with people and had a negative impact on the care and support that they were able to provide. The recording of people’s medicines was not managed safely. Plans to describe how people should be evacuated out of the building in the event of an emergency were not available for each person who lived at the home. Although members of staff told us they completed safeguarding adults training, two care assistants were unable to describe what constituted abuse.

Since our last inspection where breaches of regulation had been identified, we found staff had been receiving regular supervision. However, we found some of the supervision sessions had been undertaken by line managers who had not received training on how to carry out effective supervision sessions. We also noted that no members of staff had received an annual appraisal since our last visit.

There had been an increase in the number of staff who required, or were overdue refresher training, from the previous inspection in July 2014. Six members of staff, including registered nurses and the home manager were overdue their annual medicines training and medicines competency assessments. We also saw that medicines competency assessment certificates were not available for staff who had completed their annual medicines assessment update.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Safeguards (DoLS), and to report on what we find. These laws protect people who may lack capacity and their ability to make/be involved a particular decision at the time it needs to be made. It also ensures that unlawful restrictions are not placed on people in care homes and hospitals. Important decisions are made in the best interests of the people. We found a lack of knowledge and understanding around appropriate assessments and applications to supervising bodies for authorisations.

We were told by three health professionals who visited the home that people were not always supported to eat and drink to maintain their health, as advice and instructions given to staff were not always followed. We observed there appeared to be a lack of knowledge and confidence amongst the staff about dementia care and the ability of staff to support people with mental illnesses.

People’s care records did not always accurately reflect their needs, or contain sufficient detail or information for staff to provide adequate support. Risk assessments for people who were nursed in bed and had swallowing difficulties and were at risk of choking were not consistently applied.

Current systems to regularly assess and monitor the quality of services or identify, assess and manage risks relating to people’s health, welfare and safety were ineffective. Previously identified breaches of regulations had not led to the necessary improvements required and additional breaches of regulations were also identified during the course of this inspection.

The majority of people and their relatives told us staff treated people with kindness. We saw caring interactions between people and staff and there was a friendly atmosphere around the home. People told us they enjoyed the meals at the home. Recruitment practices at the service were thorough, appropriate and safe. Three members of staff were singled out by a health professional for the care and support they provided and we saw that referrals had been made to the challenging behaviour team in relation to two people. This had resulted in a reduction in the level of distressed behaviour for one person. The majority of staff told us staff morale had improved following the arrival of the new manager at the home. All of the staff we spoke with felt the manager was supportive and approachable.

We have recommended that the service explores the relevant guidance in dementia care and supporting people living with dementia in meaningful activities.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of the full version of this report.