Background to this inspection
Updated
1 February 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is 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.
This inspection took place on 4 and 5 January 2017 and the first day of the visit was unannounced.
The inspection team consisted of one inspector 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. The expert for this inspection had experience of caring for an older people living with the experience of dementia.
Prior to the inspection the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We reviewed the information sent to us in the PIR and notifications we had received. A notification is information about important events which the service is required to send us by law.
During the inspection, we spoke with nine people who used the service, two relatives, five staff members, including the manager, the administrator, the chef, a senior care worker and a care worker. We also met with a Trustee and the community leader who were visiting on the day of our inspection.
We looked at the environment and observed how people were being cared for. We looked at records, including the care records for four people, three staff records, staff supervision and training records, medicines records and other records relating to the management of the service.
Following our visit, we spoke with a social care professional and a healthcare professional to obtain their feedback about the service.
Updated
1 February 2017
The inspection took place on 4 and 5 January 2017. The first day of our inspection was unannounced and we told the provider we would be returning the following day to complete our inspection. The service was last inspected on 30 November 2015 when we found four breaches of the Health and Social Care Act 2008 and associated regulations relating to the management of medicines, the Mental Capacity Act 2005 and good governance. Following the inspection the provider sent us an action plan detailing how they would make improvements. At this comprehensive inspection we found the provider had taken action to address the breaches we had identified and improvements had been made.
Marian House Nursing Home offers personal care for up to 20 older people and is run by a Roman Catholic religious congregation. At the time of our inspection, 12 people were living at the service, most of whom were catholic nuns.
At our last inspection, Marian House Nursing home was registered to provide nursing care. Following our inspection, the provider made an application to remove this regulated activity and on 2 November 2016, the service became a residential care home.
The previous registered manager had left the service on 3 November 2016 and there was a manager in post at the time of our inspection who was in the process of registering with the Care Quality Commission (CQC). 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 and their relatives told us that the staff and manager were extremely caring and communicated effectively with them, responded to their needs promptly and treated them with kindness and respect. The staff team knew people well and were exceptional at delivering care that made people feel valued. The provider and manager were passionate about promoting person centred values as the basis of the service and ensured these were followed by the care staff.
The whole staff team understood the importance of ensuring people’s emotional, spiritual and cultural needs were met as well as their physical needs. All the staff had been trained in end of life care to ensure they provided sensitive and compassionate care for people who were reaching the end of their life.
The provider had taken action to meet the concerns identified at the inspection of 30 November 2015 and had put systems in place for the safe management of medicines.
The manager undertook medicines audits and ensured that staff received training in the administration of medicines and had their competencies regularly assessed.
The provider had made improvements and had acted in accordance with the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s capacity was assessed and they consented to their care and support. Processes had been followed to ensure that, where needed, people were deprived of their liberty lawfully.
People and staff told us they felt safe and there were systems and processes in place to protect people from the risk of harm. There were enough staff on duty to care for people and numbers were adjusted according to people’s needs.
There were appropriate procedures in place for the safeguarding of vulnerable people and these were being followed.
Staff received regular training, supervision and appraisal. The manager attended forums and conferences in order to keep abreast of developments within social care.
People’s nutritional and healthcare needs had been assessed and were met.
Care plans were in place and people had their needs assessed and reviewed regularly. The care plans contained detailed information and reflected the needs and wishes of the individual.
There was a complaints procedure in place and people and their relatives knew how to make a complaint. They felt confident that their concerns would be addressed. Relatives were sent questionnaires to gain their feedback on the quality of the care provided.
People, relatives and professionals we spoke with thought the home was well-led. The staff told us they felt supported by the manager and there was a family atmosphere and a culture of openness and transparency within the service.