About the service:

• The service is based within the campus of the St Mark’s Hospital community precinct, in a residential part of Maidenhead.

• The service is part of the Bupa group, which operates multiple care locations throughout England. Bupa is a ‘corporate’ provider and the registered services are part of our market oversight scheme.

• The service provided accommodation and personal or nursing care to older adults, in particular those with dementia in four units. People lived in their own bedrooms. Rooms had ensuite bathroom facilities. There were also communal bathroom facilities, lounges and dining rooms.

• The service can accommodate up to 80 people. At the time of our inspection, 74 people used the service and there were 98 staff.

People’s experience of using this service:

• St Mark’s Care Home provided exceptional care to people.

• People, relatives, staff and community professionals consistently described the service as “excellent”, “loving”, “special”, “very well-led” and a unique place to live. One relative said the service was a “gem”.

• People were always protected against avoidable harm, abuse, neglect and discrimination. The care they received was safe.

• People’s risks were assessed and strategies put in place to mitigate the risks.

• People experienced positive outcomes regarding their health and wellbeing.

• Staff received good supervision and training, which provided them with the knowledge and skills to perform the roles they were employed to do.

• People and relatives provided consistently positive feedback about the care, staff and management. They provided examples of the outstanding care at the service and how people’s lives were enhanced.

• Care was very person-centred and focused on ensuring people with dementia lived rewarding lives. The care was designed to ensure people’s maximum independence was encouraged and maintained, especially when there was an ongoing decline during their stay at the service.

• Care planning was centred around and designed by people. End of life care planning, documentation and nursing care were outstanding.

• The management team had embraced continuous learning, positive change, new ways of working and excellence in care techniques and practices.

• There was an excellent workplace culture and staff we spoke with provided glowing feedback about the management team. Staff appeared to be very content were completely committed to ensuring the best care for people and support to their relatives.

• The service met the characteristics for a rating of “outstanding” in three of the five questions we inspected. Therefore, our overall rating for the service after this inspection was “outstanding”.

• More information is in our full report at www.cqc.org.uk

Rating at last inspection:

• The service was rated “good”.

• Our previous inspection report was published on 31 August 2016.

Why we inspected:

• This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

• We inspect services already rated “good” within 30 months of our previously published inspection report.

Follow up:

• We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

St Mark’s Care Home provides accommodation and nursing care to younger and older adults, people with sensory impairments or physical disabilities and people with dementia. There is also a rehabilitation unit for people recovering from injury or surgery after discharge from hospital. The service is registered to accommodate a maximum of 80 people. At the time of our visit there were 69 people using the service.

The location was last inspected under the 2010 Regulations on 20 May 2014, where the five outcomes we inspected were compliant. This is the first inspection of the location under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the rating of the service under the Care Act 2014.

At the time of the inspection, there was a registered manager. 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 said the staff were caring and kind and treated them with dignity and respect. Staff demonstrated a good understanding of people’s care needs. We observed staff were calm and professional and not rushed whilst carrying out their care duties and in their interaction with people.

People told us they felt safe living at St Mark’s Care Home. People were safe from abuse and neglect. Staff we spoke with were knowledgeable of how to act if abuse occurred and how to report this to managers or other authorities.

Proper maintenance of the premises and grounds was evident. The registered manager and maintenance staff were knowledgeable about risks from the building and completed assessments and coordinated repairs to effectively prevent harm to people.

We examined records about staffing deployment and observed staff perform their roles. We found that during peak periods, like meal times, staff were busy but that safe deployment was evident.

People were involved and enabled to make choices about how they wanted to be supported. They were supported to follow their interests and take part in social activities People knew how to make a complaint and felt that due to the responsive nature of staff their complaints would be responded to appropriately.

Staff training, supervision and performance development was effective. Induction programmes and training occurred to ensure people were safe. Competency checks and repetition of training was carried out to ensure effective care.

People received nutritious food which they enjoyed. Hydration was offered to people to ensure they did not become dehydrated. Risks of malnutrition were assessed and mitigated where possible. Thickened drinks were used for some people, but these needed review to ensure staff followed the set plan. We made a recommendation for the service to seek and follow national guidance to ensure the best health for people with diabetes.

People and their relatives spoke positively about how the service was managed and how the registered manager contributed to this. Staff spoke positively about the support they received from management. The service had comprehensive quality assurance systems to assess monitor and improve the quality and safety of the service it provided.

The inspection was carried out by two inspectors and one CQC pharmacist inspector to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People told us they felt safe and secure. They said they would approach staff if they were worried about their safety or worried about the services provided. They told us they had a call bell should they require assistance comments included: “in this place you push a buzzer and something happens fairly quickly”.

The provider and staff understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were able to describe the circumstances when an application should be made and knew how to submit one.

People’s care plans detailed how the person wanted their needs to be met. Risk assessments identified risks associated with personal and specific health related issues, and recorded guidance for staff to minimise those risks. However, ineffective monitoring of peoples pressure care had placed them at greater risk of developing pressure sores as some records werenot accurate to promote continuity of care. Pressure care mattresses were not monitored effectively to ensure they were at the right setting to minimise risk. The provider had taken immediate steps to ensure this area of non-compliance was resolved immediately.

Systems were in place to safely store and administer medicines. Supporting information for medicines about allergies, “variable dose” and “if required” was recorded to support staff administer medicines safely. However we told the provider that in a few records the supporting information was inconsistent for “how the service user took their medicines”. Audits were undertaken to monitor the safe use of medicines and to improve the processes.

Recruitment procedures were rigorous and thorough

Staff had received health and safety training. Procedures for dealing with emergencies were in place and staff were able to describe these to us.

Is the service effective?

People were involved in their care planning and knew what actions would be taken to support them.

People we spoke with who lived in the home or were receiving services of rehabilitation within the short stay unit told us: “staff are great”, “no criticism about the staff, all nice and all helpful”.

People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. People's individual interests were identified and used to enhance people's lifestyle. One-to-one activities were provided for people who remained in their room due to ill health or choice.

Is the service caring?

We saw that care staff interacted positively with people who used the service and were sensitive to people’s needs. Staff were observed to approach people in a respectful and appropriate manner.

People we spoke with told us staff were considerate and kind. One comment included: “all the medical staff and care staff are very good. I watched them yesterday attend to a lady who was feeling unwell – I observed they treat you here as a person, it is less clinical than a hospital”.

Is the service responsive?

The home had made changes and improvements as a result of ideas and discussions with people who lived in the home and their relatives.

People knew how to make a complaint if they were unhappy. People told us they knew who to complain to and that the manager and staff were approachable. The home recorded seven complaints since our last inspection in November 2013 and these were investigated.

Is the service well-led?

The service had a robust quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was being maintained or improved.

Staff told us that they had the support of a manager and could get assistance from senior managers, as necessary. We saw that the home had a stable staff group who had worked in the home for a number of years. Staff told us that they worked well as a team and were provided with guidance and support in line with the provider’s policies and procedures.

In October 2013, we were alerted to allegations of unsafe care and perceived poor outcomes for some people who use the service at St Mark’s Nursing Centre. In particular, the issues related to the Henley unit, a 20 bedroom section of the home. At that time, the Henley unit was completely commissioned by a local clinical commissioning group (CCG) and accepted admissions from local hospitals to assist people with rehabilitation before they returned to their own homes or other suitable accommodation.

We checked our monitoring systems and liaised with commissioners who used the Henley unit and other units at the location to accommodate people. We were advised the provider was investigating concerns raised with them regarding some of the staff at the home. We also noted an increase in the number of statutory notifications we had received from the provider relating to alleged abuse and actual serious injuries. We spoke with the local authority and the provider about these matters to gather further information.

The inspection was conducted by two compliance inspectors, a pharmacist inspector and a specialist advisor. On the day of the inspection, the registered manager was on planned leave. The location was temporarily managed by the deputy manager, with support from the provider’s interim regional manager. The primary focus of our inspection was the Henley unit, however we also checked to ensure that the needs of people who lived in other units were being met.

We found people’s privacy, dignity and independence were respected. We saw people were spoken to appropriately by staff and that people’s independence was facilitated by a range of functional activities.

We found the provider did not always ensure that people who use the service experienced effective, safe and appropriate care or treatment and support which met their needs. There was a risk that people would not be protected from receiving care that was inappropriate or unsafe.

We found there were breaches with the regulation regarding the management of medicines. We saw medicines were sometimes not stored safely, that recording of the administration of medicines was unsatisfactory and that people’s ability to self-administer medications had not been accurately assessed.

We found mixed evidence about the compliance with the regulation pertaining to assessing and monitoring the quality of service provision by the provider. In some areas of monitoring, there were robust and satisfactory methods of ensuring people who use the service were safe. However, we found that some systems used at the location identified risks to people that were not fully assessed or monitored to ensure the risks did not impact on people’s welfare or care outcomes.

We found issues with the security of confidential information about people who use the service. During part of our inspection, we found confidential documents in a communal area that were available for passers-by to view. We also found that parts of people’s risk assessments, care plans and care documentation were incorrectly completed or not completed at all.

We spoke with five people who use the service and four relatives about involvement in decision making. They told us people were free to make decisions about their care.

People’s needs were assessed. Care and treatment was planned and delivered in line with their individual care plan. The provider had introduced a change in the system for completing risk assessments and care plans for people who use the service and this had changed the way care was planned and delivered. We saw an improvement in the way risks were assessed and care was planned as a result of this change.

Appropriate checks were undertaken before staff began work. We looked at a selection of personnel files for staff that had worked at the location prior our last inspection. We saw the registered manager had ensured that the appropriate documentation was now available on the personnel files.

The provider took account of complaints and comments to improve the service. The provider had a system in place known as “personal best” where people and others could provide feedback about individual care workers to the registered manager. We reviewed five feedback cards from July 2013 completed by people who use the service. One person said, “X you are one in a million. Your butter cream cakes are also one in a million like you. Thank you very much”. Another person wrote, “X has a wonderful understanding of people’s needs and understanding of all aspects, for a young person".

In this report the name of a registered manager appears who was not in post and not managing the regulated activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual's name from our register.

We used a number of different methods to help us understand the experiences of people who use the service because some people had complex needs and they were unable to tell us their experiences. Other people who use the service were able to communicate with us about their experiences. We spoke with 13 people who use the service, 12 relatives and 7 staff. We also spoke with the acting home manager, the new home manager, the provider's quality consultant and the acting regional manager.

We looked at four people's care documentation in detail. We saw risk assessments for various aspects of people's care. Care plans complemented and accompanied the risk assessments we viewed.

We observed the dining experience in three out of four units. We saw the dining rooms were set up in a way which was conducive to encourage people to eat and participate in a social dining experience.

We looked at 10 staff recruitment files. We found some evidence required by the regulations missing from eight of them.

Generally people said they were well cared for and the staff were good.

People told us that staff respected their privacy and dignity while carrying out personal care.

People said they were happy living at the home and felt able to raise concerns with the manager.