CQC report explained · a nursing home
What the CQC found at St Marks Court
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved risk assessments, safer medicines management, suitable safeguarding systems and safe recruitment. They also found some cleanliness and maintenance problems, and recommended keeping staffing levels and deployment under review.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating, but that rating is not stated in the report text provided.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating, but that rating is not stated in the report text provided.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward into the overall rating, but that rating is not stated in the report text provided.
- Well-led?
- Requires improvement
- Management and quality monitoring had improved, but leadership was still inconsistent. Inspectors said more work was needed on menus, refurbishment, staff deployment and the design of the environment.
What inspectors found, October 2022
St Marks Court is rated Good overall, but inspectors found leadership still Requires Improvement and identified concerns about staffing, menus and the building.
This was an unannounced, focused inspection. Inspection activity started remotely on 5 September 2022 and ended on 26 September 2022, when inspectors visited the home. They spoke with people, relatives, staff and health professionals, observed care and checked care, medicines, recruitment and management records.
The Safe rating improved to Good. Inspectors found better risk assessments, safer medicines systems, suitable safeguarding arrangements and safe staff recruitment. However, some areas were not clean or well maintained, and people said staff were very busy and did not always have time to spend with them.
The Well-led rating remained Requires Improvement. Management systems had improved and the home was no longer in breach of Regulation 17. Further work was still needed on menus, refurbishment, staffing arrangements and the design of the environment. The overall rating changed from Requires Improvement to Good because the other key questions were not inspected at this visit and their previous ratings were carried forward.
Improved risk management
Care records gave staff clearer instructions about people's risks and needs. Risk assessments were reviewed and measures were put in place to reduce harm.
“Records were more detailed and showed risks were assessed, with measures put in place to remove or reduce the risks.” from the report
Safe medicines
Inspectors found medicines were managed safely and records supported staff to give medicines as prescribed.
“Medicine administration records assured us medicines were given as prescribed.” from the report
Kind and supportive staff
People and relatives spoke positively about the staff. Inspectors saw care being given discreetly and compassionately, with people's privacy respected.
“All people and relatives were complimentary about the care provided by staff.” from the report
Better governance
Quality monitoring systems had improved since the previous inspection. The home was no longer in breach of Regulation 17.
“At this inspection improvements had been made and the service was no longer in breach of the regulation good governance” from the report
Staff availability
needs fixingAlthough staffing was judged sufficient for safety, people and relatives said staff were very busy. One person said staff did not have enough time to spend with them, and another reported a long wait for the call bell.
“When I press my buzzer, they [staff] do take a very long time in answering.” from the report
Cleanliness and wear
needs fixingSome carpets were marked and parts of the home showed wear and tear. The provider supplied an action plan and refurbishment programme after the inspection.
“Some carpets were marked and some areas were showing signs of wear and tear.” from the report
Leadership and the environment
needs fixingThere was no registered manager in post during the inspection. Further improvement was also needed in menus, refurbishment, staff deployment and the design of the home.
“Some improvements were still required to menus, refurbishment, staff deployment and environmental design of the service.” from the report
- 01How quickly are call bells answered now, and how do you monitor this?
- 02What staffing levels and deployment arrangements are currently in place to give people enough time and company?
- 03What refurbishment has been completed since the inspection, including replacing marked carpets and improving cleanliness?
- 04What changes have been made to the menus, including food variety and presentation?
- 05Is there now a registered manager in post, and how are quality improvements being monitored?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 7 October 2022 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, January 2022
St Marks Court is rated Requires Improvement; inspectors found caring staff and safe medicines, but risk records and quality checks were not reliable enough.
This was an unannounced focused inspection. Inspectors visited on 3 November 2021 and continued inspection activity until 16 November. They spoke with people, relatives, staff and visiting professionals, observed care, and checked care, medicines, staffing and management records.
The home was not always safe because some risk assessments lacked detail or conflicted with other records. Staff did not always record actions such as position changes and pressure mattress checks. Some staff were also not confident using the electronic care planning system.
The home was not always well-led. Audits had failed to identify these problems, and this breached Regulation 17 on good governance. Inspectors also found enough trained staff, safe medicines management, safeguarding arrangements, infection controls and a positive culture.
The overall rating changed from Good to Requires Improvement. Only Safe and Well-led were inspected at this visit. The ratings for the other areas came from the previous comprehensive inspection.
Enough staff
Inspectors found enough staff to meet people's needs. Recruitment checks were also carried out safely.
“The provider employed sufficient staff to keep people safe.” from the report
Medicines
Staff were trained and competent to give medicines. Medicines audits and stock checks were carried out, although one recording issue was missed.
“Staff were appropriately trained and competent in the administration of medicines.” from the report
Positive culture
Inspectors observed kind and inclusive interactions. Most people and relatives spoke positively about the care and support.
“The provider had created a positive culture amongst the people and staff.” from the report
Infection control
Inspectors were assured about the home's infection prevention arrangements, including protective equipment, testing, hygiene and visits.
“We were assured that the provider was using PPE effectively and safely.” from the report
Incomplete risk information
seriousSome risk assessments did not clearly explain what staff should do and when. Information could conflict between different parts of a care plan, which could cause confusion.
“Some risk assessments did not include what staff needed to do and when to keep people safe.” from the report
Actions not always recorded
seriousStaff did not always record risk-reducing actions, including position changes and pressure mattress checks. This made it unclear whether these actions had been completed.
“Staff did not always record risk-reducing actions such as people's positional changes and pressure mattress checks.” from the report
Care planning system
needs fixingSome staff were not confident using the electronic care planning system because induction had not included enough specific training time. Additional training was underway.
“Recent inductions of new staff had not included enough specific time to learn the electronic care planning system.” from the report
Weak quality checks
seriousThe home's audits had not identified problems with care plans and risk assessments. The provider was in breach of Regulation 17.
“The provider's failure to ensure effective quality monitoring systems were in place was a breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Medicine recording
needs fixingMedicines were managed safely overall, but audits had not found inconsistent recording of time-sensitive medicines by some staff.
“However, audits had not identified the inconsistent recording of time sensitive medicines by some staff.” from the report
- 01What changes have you made to risk assessments so they are person-centred, consistent and clear for agency staff?
- 02How do you check and record position changes, pressure mattress checks and other risk-reducing actions?
- 03What training has every staff member received on the electronic care planning system, including new starters?
- 04What action was included in the improvement plan for the Regulation 17 breach, and has it been completed?
- 05How do you now check the recording of time-sensitive medicines?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 15 January 2022 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 St Marks Court
8 rated inspections over 8 years: the service has improved, from Inadequate to Good.
- October 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2021Inspected but not ratedSafe: Inspected but not rated
- May 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- August 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 1 November 2011.
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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48 live-in carers within about an hour of Gateshead
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,240 a week. 42 can care for a couple. 10 years' experience on average.
“Petty introduced herself to Mum every time she was caring for her and responded very quickly to Mum if she was distressed in the night.”
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