CQC report explained · a residential care home
What the CQC found at Simon Marks Court
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2020
Simon Marks Court was rated Requires Improvement because safety and management systems were not reliable, although care, support and responsiveness were rated Good.
This was an unannounced inspection on 28 November and 11 December 2019. Inspectors spoke with people, a relative and staff. They observed meals and shared areas, and checked care, medicines, recruitment and management records.
People were treated kindly and with respect. They were supported to make choices about their daily routines, food and care. Staff were trained, the home was clean and there were enough staff to keep people safe.
However, some risks, including falls, pressure sores, weight loss and distressed behaviour, were not managed well enough. Medicines records were not always clear. Management checks had missed problems, and important care and incident records were not always complete or easy to find.
Kind and respectful care
People were treated well and staff supported their dignity, privacy and independence. Staff knew people and responded to signs of distress.
“People were treated well and enjoyed living at the service.” from the report
Food and drink
People had enough to eat and drink and were offered choices, extra portions and regular snacks and drinks. The previous nutrition and hydration breach had been resolved.
“People had plenty to eat and drink. Staff offered extra portions and checked everyone had enough to eat.” from the report
Staff training and support
Staff received induction, training, updates and supervision. Recruitment checks were described as robust.
“Staff were equipped to perform their roles. They received appropriate induction, training and regular updates.” from the report
Choice and personalised routines
People could choose when to get up and go to bed, where to spend time and what to eat. Their end of life wishes were recorded.
“People received person centred care. They shared examples of how the care they received met their preferences and wishes.” from the report
Clean and suitable environment
The home was clean, well maintained and furnished to a good standard. People had access to different communal areas and an enclosed outside space.
“People lived in a pleasant and well-maintained environment. The service was decorated and furnished to a good standard.” from the report
Risks were not consistently managed
seriousAssessments for falls, pressure sores, weight loss and distressed behaviour were not always effective. Staff did not always follow safety guidance, including using a movement sensor.
“The service did not always assess and manage risk. Assessments around managing behaviours that challenged, falls, pressure sores and weight loss were not always effective.” from the report
Safety incidents were not fully recorded
seriousSome incidents involving distressed behaviour were recorded in different places or not recorded on an incident form. This made it harder for managers to review events and identify patterns.
“Incidents where people displayed behaviours that challenged were not always monitored.” from the report
Medicines records needed improvement
needs fixingSome people did not have clear guidance for medicines given when needed. Records did not always show clearly whether time-specific medicines had been given.
“Systems for making sure people received time specific medicines correctly were not robust.” from the report
Management checks missed problems
seriousAudits did not identify issues found by inspectors. Care records were disorganised, and some relevant records had been archived or could not be found.
“Quality management systems were not always effective. The provider's auditing and monitoring had not highlighted issues that were raised at the inspection.” from the report
Care plans lacked some detail
needs fixingStaff sometimes relied on handovers rather than reading care plans. Some plans did not give enough information about how people's nutritional needs should be met.
“However, some care plans lacked detail, for example, around meeting nutritional needs.” from the report
Activities were still developing
minorFeedback about activities varied. A new approach was being introduced, but the report said it needed time to become effective.
“The service was developing and improving social opportunities and activities.” from the report
- 01How are you now assessing and managing risks relating to falls, pressure sores, weight loss and distressed behaviour?
- 02How do you make sure movement sensors and other safety guidance are used correctly every time?
- 03How do you check that medicines given when needed and time-specific medicines are administered and recorded correctly?
- 04How have you reorganised care records so staff can find current information and use care plans rather than relying on handovers?
- 05What progress has been made with the new activities programme and the additional dining area?
This was an unannounced planned inspection of the care home covering all five CQC questions, including the premises and care provided. This explanation was written from the published report of 21 February 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2018
Simon Marks Court was rated Requires Improvement; inspectors found kind care and enough staff, but safety, mealtimes, medicines records and management checks needed improvement.
Inspectors carried out a comprehensive inspection on 14 and 15 November 2018. It was unannounced on the first day and announced on the second day so the registered manager would be available. They spoke with people, relatives and staff, observed care and mealtimes, and checked care plans, medicines, staff records and management audits.
The home was warm and friendly. People and relatives spoke positively about the care. Staff treated people with dignity and respect, supported access to health professionals and provided activities. There were enough staff, recruitment checks were completed, and staff had training, supervision and appraisals.
However, some safety risks were not managed well. Inspectors found an unlocked door leading to steep stairs, an unlocked cupboard containing cleaning products, incomplete emergency evacuation plans and weaknesses in medicines records. Mealtimes were sometimes noisy, cramped and disorganised, and records about food and fluids were not always complete.
The overall rating means the home was not consistently meeting the required standard. The caring and responsive questions were rated Good, while safe, effective and well-led were rated Requires Improvement. The home had been rated Good at the previous inspection in May 2016.
Kind relationships
People and relatives spoke positively about the care. Inspectors saw staff talking kindly with people and supporting them in a friendly way.
“Through our observations we noted staff talking kindly and being friendly and caring towards people.” from the report
Enough staff
Inspectors found enough suitably deployed staff on both inspection days. Staff and people also said that help was available quickly.
“There were sufficient numbers of suitably deployed staff to meet people's needs on both days of our inspection.” from the report
Staff checks and training
The home completed recruitment checks, inductions, training, supervision and appraisals. Relevant staff had medicines training and competency checks.
“Records showed safe recruitment practices were followed.” from the report
Health support
People could access health professionals when needed. Care records showed contact with GPs, chiropodists and dieticians.
“We saw evidence in care plans staff had worked with various healthcare professionals and made sure people accessed other services in cases of emergency, or when people's needs had changed.” from the report
Safety risks
seriousAn unlocked door led to steep basement stairs, and an unlocked cupboard contained a cleaning product. Emergency evacuation plans did not fully explain the support each person would need.
“Some areas of the home and people's records were not safe.” from the report
Medicines records
seriousCreams, pain patches, fridge temperatures and as-required medicines were not always recorded or clearly instructed. This meant staff could not always show that medicines were given as prescribed.
“Care and treatment was not provided in a safe way as records for the management of medicine was not robust.” from the report
Mealtimes
seriousBreakfast and lunch were sometimes noisy, cramped and disorganised. Some people waited a long time for food or drinks, and staff did not always know who needed help.
“We did not observe a positive mealtime experience for people, this was task orientated.” from the report
Management checks
seriousAudits did not consistently identify or resolve problems. Records about food, fluids, care plans and incidents were incomplete or inconsistent.
“The registered provider did not have fully effective systems in place to assess, monitor and improve the quality of service provided.” from the report
- 01What action has been taken to secure the door to the steep basement stairs and the cupboard containing cleaning products?
- 02How are medicines, creams, pain patches and medicine fridge temperatures now recorded and checked?
- 03How do you make sure every person gets the right support promptly during meals?
- 04How are personal emergency evacuation plans kept up to date with each person's moving and handling needs?
- 05How do your audits now identify and follow up missing food, fluid, care plan and incident records?
This was a comprehensive inspection covering the premises and care provided, with all five CQC questions assessed. This explanation was written from the published report of 19 December 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Simon Marks Court
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- February 2020Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2015Inspected but not ratedEffective: Good
- December 2014Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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