Background to this inspection
Updated
7 March 2019
The inspection:
• We carried out our inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. Our inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
Inspection team:
• Our inspection was completed by two inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. Our expert by experience had knowledge about the support of older adults within residential care settings.
Service and service type:
• St Mark’s Care Home is a ‘care home’. People in care homes receive accommodation and nursing or 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.
• The service is required to have 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. At the time of our inspection, a manager was registered with us.
Notice of inspection:
• Our inspection was unannounced.
What we did:
• Our inspection was informed by evidence we already held about the service. We also checked for feedback we received from members of the public, local authorities and clinical commissioning groups (CCGs). We checked records held by Companies House, the Food Standards Agency, fire and rescue service, environmental health and the Information Commissioner’s Office.
• We asked the service to complete a Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make.
• We spoke with ten people who used the service and six relatives. We observed the care of numerous other people who were not able to speak with us.
• We spoke with the provider's regional director, registered manager and clinical services manager. We also spoke with three registered nurses, ten care workers, the resident experience manager, two maintenance workers, the activities coordinator and the cleaning staff.
• We spoke with the GP and received written feedback from other health and social care professionals.
• We reviewed six people’s care records, six staff personnel files, audits and other records about the management of the service.
• We requested additional evidence to be sent to us after our inspection. This was received and the information was used as part of our inspection.
Updated
7 March 2019
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.