We carried out an unannounced comprehensive inspection of this service on 24 and 25 November 2014. Breaches of legal requirements were found and we issued a warning notice for a breach in relation to the maintenance of proper records. The provider was required to meet the regulation by 16 February 2015.
As a result we undertook an unannounced focused inspection on 10 April 2015 to follow up on whether action had been taken to meet the requirements of the warning notice. You can read a summary of our findings from both of these inspections below.
Comprehensive inspection of 24 and 25 November 2014.
This inspection took place on 24 and 25 November 2014 and was unannounced. At the last inspection in June 2014, we asked the provider to take action in relation to how people consented to their care and treatment, the care and welfare of people, how workers were supported, how the safety and quality of the service was monitored and the maintenance of records. The provider sent us an action plan which described the actions they were going to take to make the required improvements. Whilst at this inspection, we found some improvements had been made; further action was required to ensure that the home was meeting these and other essential standards.
Marie Louise House is a purpose built nursing home which opened in 2005. The home is owned by The Daughters of Wisdom, a religious order, and managed on their behalf by the Healthcare Management Trust. The Sisters from Abbey House convent work closely with the home providing pastoral support to the residents and their relatives. At the time of our inspection there were 45 people living at the home. The home is arranged over three floors. The Nightingale unit on the ground floor provides care for up to 10 people living with dementia some of whom were also physically frail and needed assistance with all aspects of their personal care and mobility. The Skylark and Kingfisher units provide general nursing care for up to 36 people.
Marie Louise House has not had a registered manager since June 2014. 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 and associated Regulations about how the service is run. A new manager was appointed in October 2014. They plan to make an application to be appointed the registered manager, although this has not yet been submitted.
Staffing levels required improvement. People told us that they had to wait for support and assistance. Target staffing levels were not always met and agency staff were required on a regular basis which meant staff struggled to meet people’s needs in a consistent manner.
The management of medicines required improvement. Records contained insufficient information to ensure the consistent administration of medicines to people. Medicines were not always administered safely.
Mental capacity assessments were not being undertaken with due regard to the MCA 2005. When a person lacked capacity to make decisions about their care, we were not always able to see that appropriate best interests consultations had been undertaken.
CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager had submitted an application for one person’s DoLS appropriately. However, they were not fully aware of a recent Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. There was a risk therefore that some people might have their liberty or choices restricted without the proper authorisations being in place.
People’s wishes and choices were not always listened to. Improvements were needed to ensure that all staff understood how to respond and interact with people in a manner that demonstrated to the person that they mattered and that their wishes and choices are valued.
People did not always have a detailed plan of care which ensured staff could meet their needs. People were not always receiving care in line with their care plan and people did not always receive care when they needed it.
People’s records did not always contain enough information about their needs to ensure that staff were able to deliver responsive care. Some records were not completed accurately.
Improvements were needed in relation to how the provider and manager identified, assessed and managed risks relating to the safety of people and of the quality of the service. We identified concerns in a number of areas including medicines management, the suitability and accuracy of records and staffing levels which showed that there was a lack of robust quality assurance systems in place.
Despite our findings people did however tell us they felt safe living at Marie Louise House. Most staff had received training in safeguarding adults and had a good understanding of the signs of abuse and neglect and were aware of what to do if they suspected abuse was taking place.
Safe recruitment practices were followed which made sure that only suitable staff were employed to care for people in the home.
Most people told us that they received effective care from staff who had the skills to support them. Some staff had not completed all of the training relevant to their role. However staff seemed to have a good understanding of their role and responsibilities.
There was an effective working relationship with a number of health care professionals to ensure that people received co-ordinated care, treatment and support including memory nurses supporting those living with dementia and respiratory nurses working alongside those with breathing difficulties.
People were actively supported to maintain their religious and spiritual beliefs and this was fundamental to each person’s wellbeing and the overall quality of their care. The home had close links with the Daughters of Wisdom living in the adjacent convent who provided pastoral support to people.
People knew how to make a complaint and information about the complaints procedure was displayed within the home and included in the service user guide, including how to raise concerns with the Care Quality Commission.
People said they had no concerns about the leadership of the home. We found that the manager was still getting to know the home, the people living there and the staff, but was also actively working to develop their understanding of what the home did well and the areas it needed to improve on.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which now corresponds to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.
Focused inspection 10 April 2015.
At our inspection in November 2014, the provider was issued with a warning notice as they had failed to ensure they maintained an accurate record of the care and treatment received by each person. The provider was required to meet the regulation by 16 February 2015.
As a result we undertook an unannounced focused inspection on 10 April 2015 to check whether action had been taken to meet the requirements of the warning notice.
We found that the provider had taken sufficient action to meet the requirements of the warning notice. Overall we found that people’s care plans were more detailed and were being reviewed regularly. It was evident the provider was taking action to personalise and improve the level of detail contained within people’s care plans. People’s care and monitoring records were being more consistently maintained and more accurately reflected the care and support they received.
We did find that some people’s care plans could be improved still further, for example, two of the diabetic care plans we viewed required additional information to ensure staff were able to provide an appropriate response should the person experience low blood sugar levels as well as high blood sugar levels. One person’s pain plan did not include details of the signs or behaviours which might indicate that they were in pain. Since the inspection, the provider has sent us updated care plans which address these omissions.
Measures had been put in place to drive on-going improvements of the records of people’s care and treatment. The provider had arranged for the home to have additional support from its Director of Clinical Operations, Audit and Compliance Manager and managers from other homes run by the provider. Detailed audits were being undertaken of each care plan and these highlighted clearly where improvements were still needed. Staff had received training in care planning to enhance their skills and knowledge and they were being encouraged to take accountability for, and to be part of, the work underway to improve people’s records.
We will undertake another unannounced inspection to check on all other outstanding legal breaches identified for this home.