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Inspection carried out on 5 February 2019

During a routine inspection

About the service:

Marwa Nursing Home is a care home with nursing that provides personal and nursing care for up to 38 older people. At the time of the inspection, there were 22 people living at the service.

People’s experience of using this service:

People who were able to communicate with us told us they felt safe. People who were not able to tell us about their experiences looked comfortable and relaxed in the presence of staff. They were cared for by a consistent staff team who had received sufficient training to carry out their roles. People received assistance to take their medicines as prescribed.

People were supported to access health care services and weekly visits were undertaken by the GP. People’s dietary needs were assessed and where needed, people received support to eat and drink.

People received care that was kind, respectful and responsive to individual needs. Care plans were comprehensive and reviewed each month. People and their relatives knew how to complain, although no complaints had been received in the last 12 months. No people were receiving end of life care at the time of our inspection visit.

The registered manager had a clear vision about the quality of care and service they aimed to provide. They worked in partnership with other organisations to make continuous improvements and develop best practice.

More information is in detailed findings below.

Rating at last inspection:

Good (report published in August 2016).

Why we inspected:

This was a planned inspection based on the rating from the last inspection. The service remained rated Good overall.

Follow up:

We will monitor information received about the service to inform the assessment of the risk profile of the service and to ensure the next planned inspection is scheduled accordingly.

Inspection carried out on 21 June 2016

During a routine inspection

This inspection was unannounced and took place on 21 and 23 June 2016.

Marwa Nursing Home provides accommodation and personal and nursing care for up to 35 older people who are frail or living with dementia. Accommodation is provided over two floors. At the time of our inspection 34 people were using the service.

When we last inspected the service on 20 and 22 January 2015 we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponded to regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found people’s medicine and care records required improvement. The provider had not effectively identified shortfalls in the service and had not always taken action to make the required improvements.

Following the inspection in January 2015 the provider sent us an action plan telling us how they would be addressing the concerns we found and that they will be compliant with the regulations by June 2016. At this inspection we found the provider had effectively implemented their inspection action plan. Improvements had been made and sustained over time and these regulations had been met.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The service is required by a condition of its registration to have a registered manager.

The management structure in the home provided clear lines of responsibility and accountability to all staff. The registered manager was enthusiastic and motivated to provide the best level of care possible. Staff had clearly adopted the same ethos and enthusiasm and this showed in the way they cared for people and worked as a team focussing on the people they cared for.

There were effective quality assurance processes in place to monitor care and plan ongoing improvements. There were systems in place to share information and seek people's views about the running of the home. The service gained feedback from people, relatives and staff and people's views were acted upon.

Staff were able to demonstrate their understanding of the risks to people's health and welfare and people told us they received care that met their needs. Risks were well managed with a good balance between promoting people's independence and minimising identified risks. People's care records were up to date and sufficiently detailed to provide staff with the information they needed to know how to keep people safe and meet their needs, wishes and preferences.

On the day of the inspection there was a calm and relaxed atmosphere in the home and we saw staff interacted with people in a friendly and respectful way. People were encouraged and supported to maintain their independence. They made choices about their day to day lives which were respected by staff.

Staff sought people's consent before they provided their care and support. They were still developing their understanding of the legal process and the nature of the required recording they needed to complete. Time was needed for the home to embed this learning in their practice to ensure mental capacity assessments and associated best interest decisions would always be completed in accordance with current best practice guidance.

Staff had good knowledge of people including their needs and preferences. Staff had received training to support them to effectively meet the individual needs of people. Staff understood their responsibilities to keep people safe from abuse. People said the home was a safe place for them to live. All staff were clear about how to report any concerns. There were enough staff to meet the needs of the people that lived at the home.

People li

Inspection carried out on 20 and 22 January 2015

During an inspection to make sure that the improvements required had been made

This inspection took place on 20 and 22 January 2015 and was unannounced.

Marwa Nursing Home provides accommodation and personal and nursing care for up to 35 older people who are frail or are living with dementia. Accommodation is provided over two floors. At the time of our inspection 34 people were using the service.

A registered manager was in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. The registered manager was available in the home on the day of our visit.

At the last inspection carried out on 30 June 2014 we found the provider was not meeting the regulations in relation to people’s care and welfare, consent to care, nutritional needs, safeguarding people, managing medicines safely, having sufficient numbers of staff, monitoring quality and safety and maintaining people’s records. We served three warning notices relating to people’s care and welfare, records and staffing numbers. These warned the provider that we would take further action if they did not make changes to ensure people were safe.

Following that inspection the provider sent us an action plan telling us about the improvements they were going to make. They told us they would make these improvements by 16 December 2014. During this inspection we found that the provider had taken action to address most of these issues. However, we found some improvements were still needed in relation to medicines, people’s daily records and monitoring quality and safety.

The provider had introduced some systems to monitor the safety and quality of the service provided. However, we found improvements were still needed to ensure these systems were effective in identifying issues of quality and safety and ensuring robust action would be taken to manage the identified risks. People, relatives and staff acknowledged there had been progress towards a stable management team in the home, and spoke with confidence about the manager in post at the time of our inspection. They told us they had seen improvements in the care provided.

People and their relatives told us they felt safe in the home and thought people received safe care. Although we found no medicine administration errors, people’s medicine records were not always sufficiently robust to prevent errors from occurring. Risks associated with people’s care were identified and managed to help keep them safe. Recruitment practices were robust to protect people as far as possible from individuals who were unsuitable to deliver care to people. The provider had employed more nurses and we found there were enough staff, based on people’s needs, to keep people safe.

People and their relatives were encouraged to be involved in the planning of people’s care. A new comprehensive care planning system had been introduced. People had care plans in place to support them to stay healthy with input from appropriate professionals. Daily records still did not accurately reflect the care people received and therefore nurses could not judge from people’s daily records whether the care plans they had instructed staff to implement, had been effective.

Where people lacked the capacity to agree to the restrictions the provider placed on them to keep them safe, the provider made sure people had the protection of legal authorisation instructing them to do so. Records did not show restrictions were only placed on people as a last resort after less restrictive approaches had been exhausted. We recommend the provider seeks guidance on how to record the best interest decisions that lead to Deprivation of Liberty Safeguards (DoLS) applications being made for people.

People were cared for by staff who were kind and respectful of their needs and wishes. Their dignity was promoted through thoughtful consideration by staff. The provider’s complaints process ensured people’s concerns were addressed appropriately. Since our previous inspection in June 2014 structured staff supervision had been re-introduced. Staff told us they received sufficient support and guidance to enable them to fulfil their roles effectively.

People and relatives were encouraged to give their views about the home and their feedback was used to make improvements. People and their visitors and relatives were complimentary about the quality of care provided. They liked the friendliness of staff, and the homely atmosphere.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 these now correspond 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 this report.

Inspection carried out on 26, 27, 30 June 2014

During an inspection in response to concerns

The inspection was carried out over a period of three days by three Care Quality Commission (CQC) adult social care inspectors and a specialist pharmacist inspector. At the time of our inspection 31 people were using the service. As some people lived with dementia, we were only able to speak with four people. We spoke with the relatives of three people and one person’s representative. We also spoke with three nurses, six care and catering staff, three managers, an administration clerk and three visiting professionals. At the time of this inspection the registered manager was working out a notice period having tendered their resignation from the post on 12 May 2014.

We observed how staff supported people and looked at documents including care plans, staff rotas and records relating to the management of the service.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer five key questions; is the service safe, effective, caring, responsive and well-led.

This is a summary of what we found. The summary describes what people’s relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

Overall we found that the service was not caring. People told us that generally staff were caring and this was supported by the positive interactions with people we saw during the inspection. However, a relative told us that they experienced difficulty in obtaining up to date information and always had to ask about the person’s care and well-being.

We noted that some people’s care plans were incomplete and as a result significant guidance to staff on matters such as pain management were not always provided.

Staff that we spoke with were concerned that people and relatives might think that they were incapable and uncaring because the service was being supported by the Community Care Team (CCT). The CCT was in the service providing nursing support. One member of staff said, “I know that neglecting people is a kind of abuse and I hope we don’t do that”.

Is the service responsive?

The service is not responsive. The registered manager cited a reason for their resignation as the on-going failure of the provider to respond to requests to increase the number of nurses employed by the service. They felt this compromised the standard of care and treatment the service was able to provide.

Visiting health professionals expressed concern that the service did not respond promptly when people’s health deteriorated or to feedback from people and their representatives. We noted a failure to refer people for specialist treatment in a timely way. This impacted adversely on people’s welfare and quality of life.

The provider’s complaints policy was unfit for purpose and was not confidential. As a result it had fallen into disuse and provided little or no information to assist with the improvement of the service.

We found that the service was unresponsive to people’s preferences regarding food and drink and that appropriate adjustments to people’s diet had not been recorded, so that their nutritional requirements could be met consistently.

During the inspection we were made aware of a serious safeguarding matter which had been brought to the attention of the registered manager. However, the service had failed to respond in accordance with the local authority guidance on safeguarding vulnerable adults and the matter had not been reported or investigated.

Is the service safe?

The service was not safe. Nursing staff from the CCT had been providing additional staff training, and care and treatment to people living in the service. This was as a result of concerns they noted in the standards of some nursing care being delivered by Marwa Nursing Home staff..

Three out of four people we spoke with told us they felt safe living in the service. A fourth person told us they had been bullied by a member of staff.

An overview of staff training was not available and we noted an over reliance on audio visual presentations identified by the provider as a requirement.. As a consequence we were not assured that staff had been trained to care for and support people to ensure their safety and welfare

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to nursing homes such as Marwa Nursing Home . During the inspection we became aware of a person living in the service who was subject to a level of control that required authorisation, though none was in place.

Because some care plans, risk assessments and risk reduction measures were incomplete, any new staff, especially those unfamiliar with people’s needs, such as agency staff, did not have sufficient guidance to ensure that they consistently and safely met all of people’s identified care and treatment needs.

Is the service effective?

The service was not effective because we found inadequate numbers of nursing staff had been employed to meet people’s needs. This resulted in the registered manager performing two roles and prevented them from fulfilling their primary function of providing clear leadership and direction at the service.

Although the service had recently sought feedback from people and their relatives on the quality of the facilities and services in order to help monitor its effectiveness, the 17 responses received had not been read by the provider.

We found a general lack of systems to monitor care standards and performance and the provider has allowed existing systems to fall into disuse. Staff were unsure about the threshold for recording accidents and incidents and whose responsibility this was. This meant one incident that we became aware of had not been reported to the local authority for consideration under their safeguarding guidance.

However, we saw evaluations of the effectiveness of specific care delivered, for example, in relation to resolving one person’s breathing difficulties.

Is the service well led?

The new manager for the service was appointed after the Registered Manager had left the service. Therefore the service was not well led because no time had been allocated for the Registered Manger to provide an effective handover of responsibilities to the new manager.

The use of a number of systems designed to monitor the quality of treatment and care had either lapsed or been discontinued. This included, staff supervision, the storage, management and recording of medicines and the monthly compliance auditing of the service.

We noted a failure to introduce policies and effective training to enable staff to protect people’s rights in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty safeguards (DoLS). The impact of this was that people were at risk of not having their mental capacity properly assessed or the legal processes may not have been correctly applied when determining what was in their best interests.

The management had also failed to explain adequately to staff the role of the Community Care Team (CCT) in supporting the nursing staff in the provision of care and treatment. This meant that Marwa Nursing Home staff perceived the CCT as a threat rather than an experienced resource they could draw up on. Because of this, we considered that the opportunity to maximise the benefit of this support may have been lost.

Inspection carried out on 27 January 2014

During an inspection to make sure that the improvements required had been made

This was a follow up visit to check if the provider had become compliant with the regulations following our previous inspection on 29 October 2013. We spent most of our visit observing care and found that generally people had positive experiences. Staff interacted well with people and they responded in a positive manner. We noted staff and people walking around the home together in conversation and whilst sometimes the people presented challenges to staff these were addressed in a kind and considerate manner.

Care and treatment was planned and delivered in a way that ensured people's safety and welfare.

The provider had an effective system in place to identify, assess and manage the risks to the health, safety and welfare of people using the service and others.

Some people’s records were illegible and not fit for purpose.

Inspection carried out on 29 October 2013

During an inspection in response to concerns

This was a responsive inspection visit following information of concern we received from health and social care professionals about the care and welfare of one person living at the home. Many of the people at Marwa Nursing Home were unable to tell us about their experiences in a meaningful way. To help us to understand the experiences people had we used our SOFI (Short Observational Framework for Inspection) tool. "SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us."

The SOFI tool enabled us to spend time watching what was going on in the service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences. We spent most of our visit observing care and found that generally people had positive experiences. Staff interacted well with people and they responded in a positive manner. We noted staff and people walking around the home together in conversation and whilst sometimes the people presented challenges to staff these were addressed in a kind and considerate manner. However not all people had the opportunity to take part in meaningful activity.

Care and treatment was planned however not always delivered in a way that ensured people’s safety and welfare. Infection control practices had improved and people had a more pleasant environment to spend time in.

Staff recruitment procedures had improved and staff had been properly vetted prior to starting work. People’s health and welfare needs are met by competent staff.

The provider did not have an effective system in place to identify, assess and manage the risks to the health, safety and welfare of people using the service and others.

We spoke with two people who could express a view and they told us they were happy at the home. One person said “I have only been here a couple of weeks and I think the staff are really good.” Another person told us “It’s really good here, sometimes though there could be more to keep me occupied. I see the staff trying really hard to involve everybody in doing activities, but not everyone is interested.” We spoke with relatives visiting the home and they told us they were happy with the care provided at the home. One relative told us “My mother is really well looked after here. The staff are lovely and very kind.” Another relative said “X has only been here a short time but so far she has no complaints and nor have I.”

Inspection carried out on 6 June 2013

During a routine inspection

Many of the people at Marwa Nursing Home were unable to tell us about their experiences in a meaningful way. To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) tool. "SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us."

The SOFI tool enabled us to spend time watching what was going on in the service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences. We spent time on each of the floors observing care and found that generally people had positive experiences.

People were treated respectfully and their views were taken in to account by staff. Risks to people's health and welfare were assessed and care was planned and delivered according to people's needs.

People who could express a view told us they enjoyed the food, and that if they did not like what was on the menu, the cook would provide an alternative. We spoke with people about whether or not they had a choice of food, some said they did, others said that they did not. People said the food was lovely and there was lots of it.

Some infection control practices at the home were unsatisfactory and would benefit from more stringent monitoring.

People's health and welfare needs were not met by staff who had been properly vetted.

The quality of the service at the home was monitored frequently and effectively. People expressed a high level of satisfaction with the quality of service at the home. For example, “I have always found the staff to be helpful and friendly”, “Dad was only at the home for a short while but he was well cared for and I was kept well informed” and “Excellent home love them to bits. All the staff are great.”

Inspection carried out on 18 April 2012

During an inspection in response to concerns

Many of the people at Marwa Nursing Home had dementia and therefore not everyone was able to tell us about their experiences. However we observed care being given, we spoke with five members of staff and four relatives visiting the home.

People who could express a view told us they liked living at the home. They said that the staff were good.

One person told us "this is my home and I am well looked after"

Another person told us 'staff keep an eye on me, I can do my own thing'

Relatives told us they felt able to raise any complaints and they were confident that there concerns would be responded to and dealt with quickly. They said staff were kind and caring.

People told us they knew the manager well and that she was always around to speak with.

Reports under our old system of regulation (including those from before CQC was created)