Margaret Roper House

Margaret Roper House is a residential care home providing personal and nursing care to up to 23 people. The service provides support to younger and older adults living with mental health conditions. At the time of our inspection there were 22 people using the service.

The service was purpose built and accommodation was over 2 floors. People had access to a communal lounge and kitchenette on each floor, in addition to a dining room and conservatory located on the ground floor.

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

People living at Margaret Roper House did not always benefit from a service that was safe, effective and well-led. At this inspection we found the safety, effectiveness and oversight of the service required improvement.

Practices at the service placed people at risk of harm. Systems in place to monitor, assess and improve the safety and quality of the service were not robust.

Risks to people were not always managed safely, as care plans did not always assess risks consistently or provide adequate information on how risks should be minimised and mitigated.

Although accidents were recorded, there was no evidence that risks had been analysed or that safety related themes and trends had been considered, meaning there were missed opportunities to identify and mitigate risks.

People’s care plans lacked detail, provided inconsistent information and did not always reflect people’s current needs, meaning people were at risk of receiving inappropriate care. There was a lack of management oversight to ensure records were maintained accurately.

Management of medicines was not always safe. The service did not always follow best practice guidance to ensure medicines were managed safely. Policies and procedures relating to medicines lacked sufficient information to help guide staff. Not all staff had an up-to-date competency assessment to ensure they were safe to administer people’s medicines.

The environment posed risks to people as it was not safely maintained. For instance, some internal doors were not fire safety compliant. Infection prevention and control procedures were not always effective as some communal toilets were visibly dirty. Some of the communal baths were damaged, which compromised effective cleaning.

The principles of the Mental Capacity Act were not always adhered to when seeking and recording people’s consent to their care and treatment, therefore people were not supported to have maximum choice and control of their lives.

We were not assured people’s nutrition and hydration needs were met adequately. Advice from professionals regarding people’s intake was not always evidenced as provided. Any support from staff regarding these needs, was not properly documented within care plans. We have made a recommendation for people who require support with their dietary needs, that their care plans are updated to include proper guidance for staff to follow.

Although staff were competent in their roles, some refresher courses for core training, such as first aid and moving and handling, were overdue. However, people told us they thought staff were trained and competent in their roles. We have made a recommendation that the provider ensures training for staff is provided in line with best practice guidance.

We received positive feedback from people regarding their treatment from staff. People told us they were treated and supported well and enjoyed living at the home. People appeared calm and at ease in their surroundings.

Both the provider and quality compliance team responded in a positive and proactive way to the findings at our inspection and began to work to action and address the shortfalls immediately, demonstrating their dedication to improve standards in the safety and quality of care being delivered to people living at Margaret Roper House.

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 good (published 21 December 2017).

Why we inspected

The inspection was prompted in part due to concerns received about medicines, staffing and governance. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 good to requires improvement based on the findings of this inspection.

We have found evidence the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to the management of risk, medicines, safety of premises, consent and governance systems at this inspection. We also made 2 recommendations regarding updating care plans for people with specific dietary requirements and that systems in place to train and support staff are improved.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

• People told us they were comfortable at the service and had everything they needed.

• The service had effective measures in place to reduce the risk of people spreading infection on entering the premises.

• The service had a robust infection prevention and control policy.

• The service was clean and hygienic.

• Staff and people at the service were tested regularly for COVID-19. The frequency of tests was in line with current guidance.

• Staff had developed resource packs for people to use. The packs included diaries and games to help people's wellbeing during lockdown guidance.

Further information is in the findings below.

The previous inspection was conducted on 8 March 2017. This was a focused inspection to follow up on two previous breaches for the safe administration and management of medicines. At that inspection although we found some improvements we raised a new concern around the management of medicines for people outside of the care home. For example, people going on 'home leave' or for trips out from the care home. Medicine audits (at service and senior management level) were completed, however, monitoring and audit arrangements for supporting people to receive their medicines when outside of the care home were not robust to assure people's health and wellbeing. The existing audits and governance arrangements had not identified the shortfalls we found during this inspection.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the administration and management of medicines for people who were taking their medicines out of the home to at least good. We found at this inspection that improvements had been made to ensure this practice was adhered to safely to enable people to take their medicines outside of the service. A policy and procedure was in place which staff understood and followed. Medicine audits were completed to ensure the safe management of medicines in and outside of the care home. This breach of regulation was met.

Margaret Roper House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Margaret Roper House provides nursing care and accommodates people who have mental health care needs. The accommodation is registered for 23 people. The registered provider (owner) is Nugent Care.

There was a new registered manager in post at the time of our inspection. ‘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's needs were recorded in a plan of care. Where a change in a person's needs had been identified their care plan was updated to reflect this. Information was made available to people in an accessible format.

Care records showed that people's health care needs were addressed with appropriate referral and liaison with external health care professionals when needed.

People's medicines were managed safely. Staff received medicine training to ensure they had the skills and knowledge to administer them.

Risks to people’ safety were assessed and risk management plans were in place to support people safely.

The environment and home’s equipment were maintained and subject to safety checks and service contracts.

Staff knew the different types of abuse and how to recognise and report any concerns they had.

Staff were aware of how to respect people’s rights to independence and staff told us how they empowered people to make their own decisions where able.

When people were unable to consent, the principles of the Mental Capacity Act 2005 (MCA) were followed. This included an assessment of a person's mental capacity and decisions made in the person's best interest. This could be further developed by better evidencing assessment around individual decisions for people.

People's consent was obtained prior to the delivery of any care and support though this was not consistently recorded in people’s plan of care.

People told us they were able to make individual menu requests and that their dietary needs were met by the staff. People were complimentary regarding the menu choices available to them.

Recruitment was safely and effectively managed within the home. Staff personnel files which were reviewed during the inspection demonstrated robust recruitment practices.

There were enough staff on duty to help ensure people's care needs were consistently met. People told us the staff supported them at the appropriate time.

We found staff were trained in a range of subjects which were relevant to the needs of people living at the home. Staff told us they received good support from the registered manager.

People were treated with dignity and respect and staff supported people to maintain positive and close relationships with relatives and friends.

Social activities were planned and well managed. People told us how much they enjoyed the social aspect of the home and in and outside of the care home. A person said, “There is so much always going on, it’s great.”

People at the home had access to a complaints policy and procedure should they wish to raise a concern. People told us they felt confident in raising any issue and that this would be addressed by the registered manager.

Quality assurance systems and processes were in place to maintain standards and drive forward improvements within the service. This included a number of audits (checks) on how the service was operating. Staff were complimentary regarding the new registered manager and the changes made within the service.

Feedback from people living in the home was sought to ensure they were satisfied with the overall service provision. This included the provision of meetings and surveys. The feedback we received was very positive. People told us how much they liked living at Margaret Roper House.

The registered manager was aware of their responsibilities and had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with the CQC's statutory notifications procedures.

Ratings from the previous inspection were on display within the home and these were also available for the public to review on the provider website, as required.

We asked the provider to take action to address these concerns. The provider submitted a provider action report which told us the improvements they had made to meet this breach.

We undertook a focused inspection on 8 March 2017 to check that they had they now met legal requirements. This report only covers our findings in relation to the specific area / breach of regulation. This covered two questions we normally asked of services; whether they are 'safe' and 'well led.' The question 'was the service effective', 'was the service responsive' and 'was the service caring' were not assessed at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Margaret Roper House on our website at www.cqc.org.uk.

There was a registered manager in post at the time of our inspection. 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.

Margaret Roper House is a nursing home registered to accommodate people who have mental health care needs. The accommodation is registered for 23 people. The home is owned by Nugent Care.

At this inspection we found a number of improvements. For example, medicine stocks were well controlled, Medicine Administration Records (MARS) were fully completed, the quantities of medicines received into the home and carried forward to the following month was clear and fully documented. The home had introduced a system in the medicines room to highlight to nurses, which medicines were to be given before breakfast and the medicine room was tidy and well organised. Regular medicine audits were also being completed to help assure the safe management of medicines.

We found however concerns around the management of medicines for people outside of the care home. For example, people going on ‘home leave’ or for trips out from the care home. For two people out on a trip during the inspection they had not received their medicines. For one person their medicine had been removed from the medicine trolley for it to be destroyed. The registered manager told us care staff were unable to administer medicines as they had not been trained to do so. For the two people who did not receive their medicines there was no record in their plan of care or record of discussion with GP around not giving their medicines as prescribed. One of the two people went out on ‘home leave’ and we found records of medicines being destroyed and again no record in their plan of care as to why this had occurred.

This is a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicine audits (at service and senior management level) were completed, however, monitoring and audit arrangements for supporting people to receive their medicines when outside of the care home were not robust to assure people’s health and wellbeing. The existing audits and governance arrangements had not identified the shortfalls we found during the inspection.

This is a continued breach of Regulation 17 (1)(2)(b) 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 this report.

We conducted a focused inspection on 21 September 2016 to check that the enforcement action, for the unsafe management of medicines, which we had taken following our last inspection of 20 April and 10 May 2016 had been met. At this inspection we identified the Warning Notice had not been fully met and therefore returned to the service on 18 October 2016 to conduct a comprehensive inspection. This meant we looked at all five domains to assess whether the provider was providing a safe, effective, caring, responsive and well led service.

The provider had a recent history of not meeting requirements regarding medication safety. We had previously undertaken a comprehensive inspection of this service in November 2015 when we found a breach in regulation regarding the safe management of medicines. After this inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 20 April and 10 May 2016 to check that they had they now met legal requirements. At this inspection we found the provider still in breach of the safe management of medicines. We took enforcement action and served the provider with a statutory Warning Notice regarding medicines not being managed safely.

The service had a registered manager in post. 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.

At this inspection we found some improvements had been made with medication management however, people were still not fully protected against the risks associated with medicines because the provider's arrangements to manage medicines were not consistently followed.

Quality assurance systems were in place but these still did not operate effectively enough to ensure people medicines were managed safely.

People said they felt safe living at the home and were supported in a safe way by staff.

People’s individual needs and preferences were respected by staff. People told us staff were kind, caring and respectful in their approach. We observed positive interaction between the staff and people they supported.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. An adult safeguarding policy and the Local Authority’s safeguarding procedure was available for staff to refer to.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults.

People living at the home told us that there were sufficient numbers of staff on duty to care for them. Staffing numbers were satisfactory at the time of our inspection.

People took part in a varied social programme and people could spend time pursuing their own interests if they so wished

There was a maintenance programme and arrangements in place for checking the environment was safe. Risks associated with hazards were recorded as part of the service’s health and safety measures to keep people safe.

The menus were chosen by people who were living at the home. People were complimentary regarding the standard and choice of meals served. Specialist diets were catered for.

People we spoke with and their relatives told us that staff had the skills and approach needed to

ensure people were receiving the care and support they needed. People told us they were invited to give feedback about the home through residents’ meetings, surveys and daily discussions with the staff. Quality surveys completed by people confirmed their satisfaction for the service.

Care plans reflected people’s individual care needs and preferences. These were reviewed to reflect changes in people’s care. The care plans varied in detail however discussions with staff confirmed their understanding and knowledge around people’s care and how they wished to be supported.

Staff sought people’s consent before providing support or care. The home adhered to the principles of the Mental Capacity Act (2005). Applications to deprive people of their liberty under the Mental Capacity Act (2005) had been submitted to the Local Authority.

Staff worked with health and social care professionals to make sure people received care, treatment and support at the appropriate time.

Staff told us they felt appropriately trained and supported. Records seen showed staff received supervision, appraisals and training to undertake their job role safely and effectively.

A complaints’ procedure was available in large print and people living at the home were aware of how to raise a complaint or concern.

The culture within the service was and open and transparent. Staff and people said the home was ‘well run’ and the registered manager approachable.

Staff were aware of the whistle blowing policy and said they would not hesitate to use it.

The manager was aware of their responsibility to notify us, the Care Quality Commission (CQC) of any notifiable incidents in the home.

You can see what action we took at the back of this report.

We asked the provider to take action to address these concerns. After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 20 April 2016 and 10 May 2016 to check they now met legal requirements.

This report only covers our findings in relation to this breach specific area / breaches of regulation. This is within the 'Safe' domain. The other domains ‘Effective’, 'Caring', 'Responsive' and 'Well led' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Margaret Roper House on our website at www.cqc.org.uk.

Margaret Roper House is a nursing home registered to accommodate people who have mental health care needs. The accommodation is registered for 23 people. At the time of the inspection the home had a registered manager in post. ‘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.’

At this inspection we found that the service was still in breach of the safe management of medicines. This was because medicines were not being given as prescribed, it was difficult to see how much medication was present in the home and there was a lack of guidance and care plans for a number of medicines to be given 'when required'.

You can see what action we told the provider to take at the back of the full version of this report.

We reviewed care records and found them to be comprehensive and up to date. We found that staff were able to explain escalation processes to reflect changing health needs and this was reflected in peoples health needs assessments.

We reviewed processes in place to ensure people's nutritional needs were met and found a robust system place led by the catering team to ensure that people's needs were met and that people were involved in the process.

We found that staff were knowledgeable in safeguarding processes and there were procedures in place to protect people living at the home.

We found that there were enough staffing in place to ensure that people were supported adequately. We found that there were processes in place to account for short-term staffing concerns to ensure that staffing levels were always sufficient to ensure that people were safe and supported.

We found that there were robust audit processes in place to ensure that the premises were maintained.

People spoken with confirmed they were encouraged to express their views openly. They told us they were able to choose how they wished to spend their day and a person told us they liked the fact the staff respected their independence. We saw a number of people making their own arrangements to go out from the home, as they wished. A person told us, 'I like to do things on my own and the staff encourage me. The staff know what I like to do.'

People informed us they had been asked about their care and treatment and understood and consented to it. They told us they were happy with the care and support they received. Their comments included, 'I love it here, it's brilliant', 'I could not have better care' and 'I am really happy with the help I get.'

People told us they were happy with the way in which the home was run and that they were able to attend regular meetings so they could talk about the home and make suggestions.

Systems were in place to monitor the quality of the service and to make improvements where necessary. This ensured people benefited from safe, quality care, treatment and support.