Marie Louise House Nursing Home

Updated 22 March 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors.

Service and service type

Marie Louise House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Marie Louise House Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 31 January 2022 and ended on 9 February 2022. We visited the service on 31 January and 3 February 2022.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke with five people and two relatives about their experience of the care provided. We spoke with 11 members of staff including, the registered manager, the clinical lead, two registered nurses, two carers, an activities coordinator, trainer, housekeeping supervisor, maintenance supervisor and the chef. We reviewed a range of records. This included multiple medicine records, five staff files in relation to recruitment and records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We received feedback from eight relatives and five staff. We looked at a range of records including five people’s care records and a sample of staff supervision records. We looked at training data, quality assurance records and policies and procedures.

Updated 22 March 2022

About the service

Marie Louise House Nursing Home is a nursing care home providing personal and nursing care to up to 51 older people. The home consists of three separate floors with their own shared spaces, including lounges and activity spaces. One of the floors offered specialised care and support to people living with dementia and they had their own area of the garden which they could access safely. At the time of our inspection there were 30 people using the service.

People’s experience of using this service and what we found

People and their relatives told us they felt safe and liked living at the home. People knew who they could talk to if they had any worries or concerns. There were appropriate policies and systems in place to protect people from abuse. Staff knew how to recognise abuse and protect people.

Risks to people were recorded in their care plans. Staff demonstrated their knowledge of people and how to support them to manage their individual risks. The safety of the environment, and of equipment within it, was monitored through regular checks.

We were assured that the provider effectively managed or prevented infection outbreaks. People told us they were able to contact their family members and friends when they wanted to. The provider facilitated visits to people living in the home in accordance with government guidance.

People and staff told us there were enough staff to meet people’s needs. We observed safe staffing levels throughout the inspection and staff appeared unhurried and responsive to people. Safe recruitment processes were in place.

People received the correct medicines at the right time. Staff followed systems and processes to safely administer, record and store medicines. People received care and support which met their needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives were positive about the quality of care and support people received. People, and those important to them, worked with the management team and staff to develop and improve the service. There were a number of systems and processes in place for monitoring the quality of care. These were used to plan improvements. Where issues were identified remedial action was taken. Staff felt respected, supported and valued.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 29 September 2020).

Why we inspected We carried out an unannounced inspection of this service in relation to the Key Questions Safe, Effective and Well-led on 18 and 20 August 2020. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do, and by when, to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Marie Louise House Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.