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Archived: Marian House Care Home Good

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 1 February 2017

The inspection took place on 4 and 5 January 2017. The first day of our inspection was unannounced and we told the provider we would be returning the following day to complete our inspection. The service was last inspected on 30 November 2015 when we found four breaches of the Health and Social Care Act 2008 and associated regulations relating to the management of medicines, the Mental Capacity Act 2005 and good governance. Following the inspection the provider sent us an action plan detailing how they would make improvements. At this comprehensive inspection we found the provider had taken action to address the breaches we had identified and improvements had been made.

Marian House Nursing Home offers personal care for up to 20 older people and is run by a Roman Catholic religious congregation. At the time of our inspection, 12 people were living at the service, most of whom were catholic nuns.

At our last inspection, Marian House Nursing home was registered to provide nursing care. Following our inspection, the provider made an application to remove this regulated activity and on 2 November 2016, the service became a residential care home.

The previous registered manager had left the service on 3 November 2016 and there was a manager in post at the time of our inspection who was in the process of registering with the Care Quality Commission (CQC). 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 and their relatives told us that the staff and manager were extremely caring and communicated effectively with them, responded to their needs promptly and treated them with kindness and respect. The staff team knew people well and were exceptional at delivering care that made people feel valued. The provider and manager were passionate about promoting person centred values as the basis of the service and ensured these were followed by the care staff.

The whole staff team understood the importance of ensuring people’s emotional, spiritual and cultural needs were met as well as their physical needs. All the staff had been trained in end of life care to ensure they provided sensitive and compassionate care for people who were reaching the end of their life.

The provider had taken action to meet the concerns identified at the inspection of 30 November 2015 and had put systems in place for the safe management of medicines.

The manager undertook medicines audits and ensured that staff received training in the administration of medicines and had their competencies regularly assessed.

The provider had made improvements and had acted in accordance with the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). People’s capacity was assessed and they consented to their care and support. Processes had been followed to ensure that, where needed, people were deprived of their liberty lawfully.

People and staff told us they felt safe and there were systems and processes in place to protect people from the risk of harm. There were enough staff on duty to care for people and numbers were adjusted according to people’s needs.

There were appropriate procedures in place for the safeguarding of vulnerable people and these were being followed.

Staff received regular training, supervision and appraisal. The manager attended forums and conferences in order to keep abreast of developments within social care.

People’s nutritional and healthcare needs had been assessed and were met.

Care plans were in place and people had their needs assessed and reviewed regularly. The care plans contained detailed information and reflected the needs and wishes of the individual.

There was a complaints procedure in place and people and their r

Inspection areas

Safe

Good

Updated 1 February 2017

The service was safe.

People received their medicines safely. Staff received training in the administration of medicines and had their competencies regularly assessed.

There were enough staff on duty to keep people safe and meet their needs in a timely manner and numbers were adjusted according to people�s individual needs.

There were appropriate procedures in place for the safeguarding of vulnerable people and these were being followed.

Effective

Good

Updated 1 February 2017

The service was effective.

The provider was aware of their responsibilities and had acted in accordance with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

People�s nutritional and healthcare needs had been assessed and were met.

People were cared for by staff who received regular training and were suitably supervised and appraised.

Caring

Outstanding

Updated 1 February 2017

The service was exceptionally caring.

The provider and manager were passionate about promoting person centred values as the basis of the service and ensured these were followed by the care staff.

The whole staff team understood the importance of ensuring people�s emotional, spiritual and cultural needs were met as well as their physical needs. All the staff had been trained in end of life care to ensure they provided sensitive and compassionate care for people who were reaching the end of their life.

Staff knew people well and had developed positive relationships with them that were based on respect and empowerment. The whole staff team consistently delivered a caring and compassionate service to ensure people felt valued and led meaningful lives.

Care plans contained people's likes and dislikes and identified the activities they enjoyed, people who were important to them, their cultural and religious needs, and needs relating to their identity. People were supported by caring staff who respected their dignity, human rights and diverse needs.

Responsive

Good

Updated 1 February 2017

The service was responsive.

Assessments were carried out to ensure the service could provide appropriate care. Care plans were developed from the assessments and reviewed regularly and were signed by people.

People and relatives were sent questionnaires to ask their views in relation to the quality of the care provided.

Complaints were investigated and responded to appropriately.

A range of activities were arranged that met people�s interests.

Well-led

Good

Updated 1 February 2017

The service was well-led.

The manager had systems in place to assess and monitor the quality of the service and put action plans in place where issues were identified.

People, relatives and professionals we spoke with thought the home was well-led and that the staff and management team were approachable and worked well as a team.

The staff told us they felt supported by the manager and there was a culture of openness and transparency within the service.

There were regular meetings for staff and people who used the service which encouraged openness and the sharing of information.