Mary Rose Manor

Updated 12 January 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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 comprehensive inspection took place 17 December 2018 and was unannounced. The inspection team included 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. The expert by experience had experience of caring for older people.

Before 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 included in the PIR along with information we held about the service, for example, statutory notifications. A notification is information about important events which the provider is required to tell us about by law.

Prior to the inspection we received feedback from the local clinical commissioning group and the local authority safeguarding team. During the inspection we spoke with nine people and 14 people's relatives and a visiting doctor. We also spoke with day and night staff, which included two nurses and four care staff. In addition, we spoke with a chef, housekeeper, the administrator, the clinical lead, the deputy manager and the registered manager.

We reviewed records which included four people's care plans, five staff recruitment records, three staff supervision records, staffing rosters for the period 18 November to 23 December 2018 and records relating to the management of the service.

The service was last inspected in January 2017 and no concerns were identified.

Updated 12 January 2019

Mary Rose Manor is a nursing home registered to provide accommodation, nursing and personal care for up to 50 older people some of whom live with dementia. It is also registered to provide care to people with a physical disability, sensory impairment or mental health diagnosis. Accommodation is arranged over three floors with two lifts and stair access to each floor. There is a garden to the rear of the service. At the time of our inspection 46 people were accommodated.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

The service was run by 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.

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At this inspection we found the service remained Good.

Processes, systems and practices were in place to protect people from the risk of abuse. The registered manager ensured staff learning took place following incidents. Risks to people had been assessed and their safety was monitored. Processes were in place to ensure people’s medicines were managed safely. People were protected from the risk of acquiring an infection.

There were sufficient suitable staff to meet people’s needs. Staff pre-employment checks had been completed and the registered manager took swift action to ensure five staff without a full employment history as legally required, provided this information.

People’s care was delivered in accordance with current legislation, standards and evidence-based guidance to achieve effective outcomes. Staff were appropriately supported in their role through training, supervision and professional development. People were supported by staff to eat and drink sufficient for their needs. Staff worked together to deliver people’s care and ensured they were supported to access healthcare. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff treated people with kindness, respect and compassion and provided any emotional support they needed. People were supported to express their views and to be actively involved in decisions about their care where possible. Staff ensured people’s privacy, dignity and independence were promoted.

People received individualised and responsive care that met their often complex needs. Staff provided people with sufficient opportunities for stimulation and support to pursue their interests. People were supported appropriately at the end of their life.

People’s care was underpinned by a positive person-centred culture. Staff understood their roles and responsibilities and regulatory requirements were understood and met. People’s views on the service had been sought and acted upon. Processes were in place to ensure continuous learning took place and areas of practice that could be improved for people were identified and addressed.

Further information is in the detailed findings below.