Miramar Care Home

Miramar Care Home is a residential care home providing personal to older people and people living with dementia. Not everyone who lived at Miramar Care Home received personal care. There were 34 people receiving personal care at the time of the inspection. The service can support up to 122 people in one purpose built building.

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

People felt safe and at home at Miramar Care Home. One person told us, “It can be so miserable having to leave one’s own home, but I am made to feel so welcome here. There is never a dull moment, and I have settled in marvellously. Even though it will never be like my own home, it’s the next best thing”.

People were protected from the risks of harm and abuse and any concerns they or staff had, were listened to and acted on to keep people safe. People were treated with dignity and respect and their lifestyle and equality needs and choices were understood and respected. People had privacy.

Risks to people had been assessed. People were supported to remain independent, understand risks and take them when they wanted to. Staff supported people to remain healthy and were offered a balanced diet which met their needs. People’s medicines were managed safely. People were protected from the risk of infection.

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 had planned their care with staff. They were supported to take part in a wider range of activities. People had been offered the opportunity to share their end of life preferences.

The provider and management team had oversight of the service. They completed regular checks on the quality of care people received. People and staff were asked for their views, which were listened to and acted on to improve the service. Records of people’s care were now accurate and complete.

The registered manager understood their legal responsibilities and had shared information with us and others when they needed to.

There were enough staff working at the service each day to support people. Staff had the skills they needed to care for people and were supported by the management team. Staff were recruited safely.

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 25 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Miramar Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Miramar Care Home accommodates 122 older people and people living with dementia in one building. The service has 10 single bedrooms with en suite bathrooms and 69 apartments for one or two people. There were 58 people using the service at the time of our inspection. Three people did not receive any care or support. Two people moved in to the service on the second day of the inspection. Eight people lived in the Cypress suite which was a dementia unit within the service. Most people using the service were able to tell staff how they preferred their care provided.

At the last inspection on 05 June 2018 we rated the service Requires Improvement overall. We found continued breaches of Regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a new breach of Regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered provider submitted an action plan dated 22 August 2018 to detail how they planned to meet the breaches of regulations.

We undertook an unannounced focused inspection of Miramar Care Home on 04 December 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection on 05 June 2018 had been made and because information of concern had been received. The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. This is because the service was not meeting some legal requirements. During our focused inspection we found that the provider had not met all of their actions detailed in their action plan.

No risks or concerns were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

A registered manager was leading the service and was supported by a management team and the provider. A registered manager is a person who has registered with CQC to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider did not follow safe recruitment practices. Gaps in employment histories had not been explored to check staff suitability for their role.

At the last inspection registered persons had failed to deploy sufficient numbers of staff to meet people’s needs. Since our last inspection the registered manager had reviewed people’s care needs and the layout of the building. To support more efficient staff deployment the building had been divided into individual units and people were being given the opportunity to move to new apartments in these units. Some people had taken up this offer and had moved and further moves were planned. Despite these changes, staff deployment remained a concern. People had mixed views on the response times to call bells. Meal times and first thing in the morning when people wanted to get up and ready were key times of the day where staff were busy providing care and support and responding to people’s needs. Call bell records evidenced some people often had long delays to receiving an answer to their call. This is an area for improvement.

At the last inspection the registered provider had failed to ensure the proper and safe management of medicines. Although some improvements had been made, medicines continued to be an area of concern. People who were prescribed topical medicines such as creams and lotions had additional topical medicines administration records (TMAR) in place, these had been completed inconsistently. Most people who were prescribed ‘as and when required’ (PRN) medicines to manage different minor ailments as well as pain or constipation. Some people did not have PRN guidelines in place to advise staff the reasons the medicines could be given, when they should give the medicines, how many could be safely taken in a 24 hour period and what were the side effects to watch out for.

At the last inspection the registered provider had failed to do all that is reasonably practicable to mitigate risks to people. At this inspection some people continued to be at risk because identified risks were not monitored. People who relied on equipment such as hoists and slings to help them manoeuvre from one place to the next had not been suitably assessed. Mobility risk assessments had not always been updated in a timely manner following a fall.

People continued to be protected from abuse. Policies were in place and available to staff. Staff were confident that any concerns they raised would be addressed quickly.

The service looked and smelt clean. Housekeeping staff carried out cleaning around the service as well as communal areas. The service had been well maintained. Repairs and maintenance of the service had been carried out in a timely manner. Since we last inspected the service, some areas on the ground floor had been redecorated and restyled. Further works were planned for other areas of the service.

At the last inspection the registered provider had failed to effectively act on feedback from relevant persons on the services provided, for the purposes of continually evaluating and improving the service. The registered provider had failed to maintain an accurate, complete and contemporaneous record in respect of each person’s care. At this inspection systems and processes were in place to monitor the service. These were not sufficient to get an oversight of what is happening in the service and whilst they had highlighted some areas of concern and action plans put in place, the systems were not robust enough to capture the breaches of regulations found during this inspection. Records relating to people’s care and the management of the service were not well organised or complete.

An improvement plan was in place based on the outcome of the last inspection. A number of dates had lapsed on the improvement plan which meant that the action to improve the service was taking longer than first identified. The regional manager agreed to send CQC an updated improvement plan each month.

The staff morale was low, staff and people felt unsettled and anxious about changes to the management team. The provider had set up ‘listening groups’ provided by the regional manager. Staff had been invited to discuss any concerns or issues they had privately and confidentially. Six staff had taken up this opportunity.

People and staff had opportunities for sharing their views. People’s views had been listened to and acted upon. The provider had implemented ‘Resident of the day’. Resident of the day includes staff spending time with people to review care plans and asking people for their feedback about their experiences of the service. People shared with us their positive experiences of resident of the day, such as time spent at the beach and having a cup of coffee.

At the last inspection the registered provider had failed to show on every website maintained by them or on their behalf the Commission’s most recent rating of Miramar Care Home. At this inspection the provider had displayed their rating in the entrance foyer and on their website.

The registered manager worked in partnership with other professionals including a clinical nurse specialist for older people.

Services that provide health and social care to people are required to inform the Care Quality Commission, (the CQC), of important events that happen in the service like a death, serious injury, abuse or deprivation of liberty safeguards authorisation. Notifications had been sent to CQC when required.

This is the third consecutive time the service has been rated Requires Improvement, which is the second consecutive time under the new provider name Avery At The Miramar (Operations) Limited. You can see what action we told the provider to take at the back of the full version of the report.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Miramar Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Miramar Care Home accommodates 122 older people and people living with dementia in one building. The service has 10 single bedrooms with en suite bathrooms and 69 apartments for one or two people. There were 60 people using the service at the time of our inspection. Most people using the service were able to tell staff how they preferred their care provided.

A registered manager was leading the service and was supported by a management team and the provider. The registered manager had been employed after our last inspection. A registered manager is a person who has registered with CQC to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 2 May 2017, we asked the provider to take action to make improvements to the way the service was managed, including complaints management, acting on people’s views, the deployment of staff to meet people’s needs and how they supported staff to fulfil their role. We also required improvements were made to the way in which risk associated with people’s care and emergency situations were assessed and mitigated.

At this inspection we looked to see if the action the provider had taken had been effective. The company which owned Miramar Care Home had been sold to Avery Healthcare approximately four weeks before our inspection. They had not changed anything at the service in this time and had plans in place to make gradual changes with the registered manager and staff to improve the service.

The registered manager had made improvements to the service. However, further improvements were needed address the continued breaches of three regulations, including how risks to people were managed, how staff were deployed at busy times of the day and how people’s views were used to improve the service. We found two new breaches of regulation.

Action had not been taken since our last inspection to deploy more staff at busy times of the day and people continued to wait for long periods of time for the support they needed. People and staff continued to raise their concerns about this with the registered manager but action had not been taken to address them.

Staff, including nurses, had met with a manager since our last inspection to discuss their role, any problems they were experiencing or their personal development. However, these meetings were not held regularly. Nurses had not received clinical supervision to support them to maintain and develop their skills. Staff, including nurses, had been supported to complete the training they needed to fulfil their roles since our last inspection. Some staff held recognised qualifications in care.

People, their relatives and staff had been asked for their views of the service. These had not been reviewed and used to improve the service. For example, 12% of people had said they did not feel safe at the service but action had not been taken to address this. Checks and audits of the service had been completed but these had not identified the shortfalls we found during our inspection.

Assessments of people’s needs and risks had been completed and risks to some people, such as weight loss had been identified. Plans had been put in place to mitigate the risks but records of the action taken had not been maintained. Checks could not, therefore, be completed by staff and visiting health care professionals to make sure the planned care was always provided to people and was effective. Detailed information was now available to staff about people’s preferences and people told us staff provided their care in the way they preferred.

People’s medicines were not always managed safely. On occasions new medicines were not obtained promptly to begin to relieve people’s symptoms. The application of prescribed creams had not been recorded so staff could check they were being used as prescribed and were effective. Records of people’s ‘when required’ medicines were not always detailed and there was a risk that these would not be managed safely.

Services are required to prominently display their CQC performance rating. The provider had displayed the rating in the entrance to the service but it was not displayed on their website.

People received the care and support in the way they preferred at the end of their life. We have made a recommendation to support the provider to improve the planning of end of life care.

The registered manager supported staff to work as a team and staff were now motivated and felt supported. The registered manager and staff shared a vision of a good quality care.

Since our last inspection the provider had acted on advice from the local fire and rescue service to make improvements to the way people were protected in an emergency. These had been effective and staff had the knowledge and skills they needed to keep people safe in the event of a fire.

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 support this practice. The registered manager knew when assessments of people’s capacity to make decisions were needed. Information was available to people in a way they understood to help them make decisions and choices. Information about who had the legal power to make decisions about people’s health and welfare was now available to staff.

Changes in people’s health were identified and staff contacted people’s health care professionals for support. People were offered a balanced diet and food they liked. The registered manager had received, investigated and resolved people’s complaints to their satisfaction.

The required checks had been completed on staff before they had begun working with people including Disclosure and Barring Service (DBS) criminal records checks. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

Staff were kind and caring to people and treated with dignity and respect. Staff knew the signs of abuse and were confident to raise any concerns they had with the provider. People were not discriminated against and received care tailored to them.

People had enough to do during the day, including activities to keep them physically and mentally active. The service and equipment were clean and well maintained. The building had been designed to meet people’s needs and make them feel comfortable and at home. People were able to use all areas of the building and grounds and were encouraged to make their rooms feel homely.

Services that provide health and social care to people are required to inform CQC of important events that happen in the service like a serious injury or deprivation of liberty safeguards authorisation. This is so we can check that appropriate action had been taken. Notifications had been sent to CQC when required.

This is the second consecutive time the service has been rated Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report.

A registered manager was working at the service and was supported by a management team and the providers. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We inspected the service sooner than we had planned because we had received a number of concerns about people’s care from relatives and staff. One person’s relative told us, “The service was sold to us as ‘they do everything’, but it hasn’t turned out that way”. People had very different experiences of care at the service. People who required frequent support or had complex needs told us they did not receive their care when they needed it and often had to wait for assistance when they rang for help. Other people who required very little support found the service met all their needs. One person told us, “I have no concerns at all, I am well looked after”.

The registered manager did not have the required oversight of the service. They had not supported staff to work as a team and staff were demotivated and did not feel supported. Concerns staff had raised with the management team had not been listened to and acted on. Staff, including nurses, had not met with a manager to discuss their role, any problems they were experiencing or their personal development. Staff shared a vision of a good quality care but had not been supported to achieve this all of the time. Checks and audits of the service had been completed but these had not identified all the shortfalls we found during our inspection.

A system was in place to consider people’s needs when deciding how many staff were required to support them at different times of the day. This was not effective and there were not enough staff available to provide the care people needed when they needed it. Some people had to wait f to receive support to meet their basic needs, such as going to the toilet. People and staff had raised their concerns about staffing with the registered manager but action had not been taken to address them.

At our last inspection we recommended that the provider contact the local fire and rescue service for advice about keeping people safe in an emergency. This action had not been taken and detailed plans and equipment were not in place to assist people to evacuate in an emergency. We informed the local fire and rescue service of our concerns and they arranged to complete a fire safety audit of the service.

Assessments of people’s needs and risks had been completed. Risks to some people, such as weight loss which was not planned had not been identified. Action had not been taken to mitigate the risks and people continued to be at risk. Care had been planned with people to meet their needs. However, detailed information was not available to staff about people’s preferences and people told us that agency staff did not always provide their care in the way they preferred.

Staff had not completed all the training they needed to fulfil their roles including the nursing skills required to meet people’s needs. Some staff held recognised qualifications in care.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). Several people were the subject of a DoLS authorisation at the time of this inspection. Other people were not restricted and went out alone or with the support of staff if they preferred.

Some people and their relatives had raised complaints and concerns with the registered manager. These had been investigated and responded to. However, action had not been taken to resolve complaints some people had made and prevent them from occurring again, including delays in providing the care people needed.

The requirements of the Mental Capacity Act 2005 (MCA) had been met. Staff supported people to make decisions and respected the decisions they made. When people lacked capacity to make a specific decision, decisions were made in their best interests with people who knew them well. Staff making decisions with others in people’s best interests did not know who had the legal power to make decisions about people's health and welfare.

At our last inspection we found that not all the required checks had been completed to make sure new staff were honest, trustworthy and reliable. Action had been taken complete all the required checks including obtaining a full employment history with dates of employment. Disclosure and Barring Service (DBS) criminal records checks had been completed. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

Changes in people’s health were identified and staff contacted people’s health care professionals for support. People’s medicines were managed safely and people received their medicines in the ways their healthcare professional had prescribed. People were offered a balanced diet and food they liked.

Staff were kind and caring to people. However, some people told us they were not always treated with dignity and respect. Staff knew the signs of abuse and were confident to raise any concerns they had with the provider. People had enough to do during the day. Records in respect of each person were accurate and complete.

We found breaches of 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.

Signature at the Miramar provides accommodation and personal and nursing care for up to 122 older people and people living with dementia. The service is a large purpose built property. Accommodation is arranged over three floors. Two lifts are available to assist people to get to the upper floors. The service has 10 single bedrooms with ensuite bathrooms and 69 suites and apartments for one or two people. There were 70 people living at the service at the time of our inspection, five people were not receiving a care service.

A general manager was leading the service. The registered manager had recently left the service and had applied to cancel their registration. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were treated with dignity and respect at all times. Staff told us they treated people as they would like their family to be treated. People and their relatives told us that the service felt like a family and staff were kind and caring.

The general manager provided leadership to the staff and had oversight of the service. Staff were motivated and felt supported by the management team. The general manager and staff shared a clear vision of the aims of the service. Staff told us the general manager and members of the management team were approachable.

There were enough staff, who knew people well, to meet their needs at all times. The needs of the people had been considered when deciding how many staff were required on each shift. Staff were clear about their roles and responsibilities and worked as a team to meet people’s needs.

The provider’s recruitment procedures were not followed consistently. The checks they required, to make sure staff were honest, trustworthy and reliable had not been fully completed for all staff. Disclosure and Barring Service (DBS) criminal records checks had been completed. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

Staff were supported to provide good quality care and support. Staff had completed the training they needed to provide safe and effective care to people and systems were in place to continually develop staffs skills and knowledge. Some staff held recognised qualifications in care. The providers process of regular meetings between staff and a manager to discuss their role and practice had not been followed for all staff. However, staff told us they felt supported and were confident to raise any concerns they had.

Staff knew the signs of possible abuse and were confident to raise concerns they had with the manager or the local authority safeguarding team. When concerns were raised action had been taken promptly to keep people as safe as possible. Robust plans were not in place to in place to keep people safe in an emergency, including plans and equipment to evacuate people from the building. Following the inspection plans were put in place to obtain advice from the local fire and rescue service.

Staff provided the care people required in the way they preferred. People’s needs assessed and regularly reviewed to identify the care they required and any changes. Care and treatment was planned with people and reviewed to make sure people got their care in the way they preferred and support them to be as independent as possible.

People received the medicines they needed to keep them safe and well. Action was taken to identify changes in people’s health, including regular health checks. People were supported by staff to receive the care and treatment they needed to keep them as safe and well as possible.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). Risk to be people had been identified and arrangements were in place to apply to the supervisory body for a DoLS authorisation when necessary.

Systems were in place to assess if people were able to make decisions but these were not always used to assess if people could make particular decisions. When people could not make a particular decision, staff made decisions in people’s best interests with people who knew them well. Consent to care had been obtained from people. People were supported to make decisions and choices. The requirements of the Mental Capacity Act 2005 (MCA) had been met. Improvements are required to make sure information about people’s ability to make particular decisions is available to staff.

People were supported to participate in a wide variety of activities that they enjoyed, including an art club, exercise activities and social events. Possible risks to them had been identified and were managed to keep them as safe as possible, without restricting them.

People told us they liked the food at the service. They were offered a balanced diet that met their individual needs. A wide range of foods and drinks were on offer to people throughout the day and night to make sure they were hydrated and not hungry at any time.

People and their representatives were confident to raise concerns and complaints they had about the service. Some people were not satisfied with the response they received and the manager took action to change the way complaints were investigated.

Members of the management team worked alongside people and staff and checked that the quality of the service was to the required standard. Any shortfalls found were addressed quickly to prevent them from happening again and plans were in place to continually improve the service. People and their representatives were asked about their experiences of the care frequently and these were used to improve the service.

Accurate records were kept about the care and support people received and about the day to day running of the service. These provided staff with the information they needed to provide safe and consistent care to people.

Systems were in operation to regularly assess the quality of the service. People and their relatives were asked for their feedback about the quality of the service they received.

We made a recommendation to improve practice in relation to recruitment practices.

People could be confident that important events that affect their welfare, health and safety were reported to the Care Quality Commission so that, were needed, action could be taken.

In response to the notices the provider stopped taking admissions and developed an action plan demonstrating how they planned to become compliant with the regulations.

During this inspection we found that improvements had been made and the provider was compliant.

At the time of our inspection there were 66 people receiving a service from Signature at the Miramar. We spoke with people using the service and their representatives. We also spoke with the provider, the manager and staff

People told us that the provider had listened to their concerns about the service and taken action to improve the service. Staff told us they had been supported by the provider to improved service people received. We found evidence to confirm this.

One person told us, 'Overall we are quite pleased with the staff, they are very good'. Another person said, 'I think the service is remarkable'.

We found that people's privacy had improved and there were sufficient staff to meet their needs consistent and in a timely way.

People's care was planned and delivered safely to meet their needs.

People were protected from the risks of malnutrition and dehydration.

People's personal records were accurately maintained and supported staff to meet their needs.

People were complimentary about the majority of the staff, one person told us, 'the staff are very cheerful and very kind'. People told us that there were not enough staff available to meet their needs. We found that people's needs were not always met in a consistent or timely way. We judged that this had a major impact on people.

People told us they lacked privacy on occasions. We found the service was aware of this but had not taken action. We judged this had a moderate impact on people.

The provider had not taken action to ensure each person's care was safe and met their needs. Care was not consistently planned and delivered in response to people's changing needs. We judged this had a major impact on people.

People had choices about what they ate, where and when. They told us the food was good and they enjoyed it. However, we found that the service had not ensured that people were protected from the risks of malnutrition and dehydration. We judged this had a noderate impact on people

People's personal records were accurately maintained and people were at risk of receiving care that did not meet their needs. We judged that this had a major impact on them

We found that the provider had not notified us of significant events.

People told us that they were happy with the care they received at the home, and one person said 'I get to make my own decisions'. Other people said 'it is very nice here', and 'staff treat me very well'. One person said that he got on well with all the staff at the home, and would not consider leaving, as he had been there for over six years.