Archived: Marsh House

We found the following examples of good practice.

Staff had received infection prevention and control training and were regularly supported to update their knowledge and skills in relation to best practice standards.

People were provided stimulation and supported to maintain contact with their friends and family when shielding or isolating.

Staff told us they were included in daily meetings to discuss the management of Covid-19 and other infectious diseases, they told us they felt listened to.

Processes in place for putting on and taking off personal protective equipment such as masks, gloves and aprons and management of clinical waste were robust. The environment was clean and domestic workers demonstrated good understanding of best practice standards for cleaning and decontamination.

The provider had risk assessed and implemented contingency plans to ensure an outbreak of Covid-19 was effectively managed. People and staff affected by Covid-19 were individually risk assessed.

People were tested before admission and asked to isolate for a period of 14 days. Staff wore personal protective equipment (PPE) and were knowledgeable about what standard of PPE was needed and when.

Further information is in the detailed findings below.

There was no 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. However, we saw evidence the manager at Marsh House was in the process of registering.

At the last inspection on 13 December 2016, we rated the service as requires improvement. This was because developments undertaken by the provider needed to be embedded to demonstrate consistent good practice over time.

We additionally made recommendations for the provider to update their recruitment practices and to ensure staff received end of life care training. We further recommended the provider adapted the home's environment to support the independence of people who lived with dementia.

Marsh House is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, both of which we looked at during this inspection.

During this inspection, we found the provider had sustained improvements following our last inspection. One staff member said, “Since [the new manager’s] taken over it’s been a different home. She’s behind me and I’m flying.” They had additionally taken action to meet the recommendation we made about safer recruitment practices. The management team assessed gaps in employment history to ensure candidates were suitable to work with vulnerable adults.

Furthermore, the provider had developed the environment to enhance the experiences of people who lived with dementia. Bedroom doors had photographs of people from important life events, such as a picture of an individual when they worked in a public house.

Additionally, the manager had clearly documented people’s end of life care planning and related preferences. When we discussed end of life care with staff we found they had a good understanding of relevant principles.

However, care records we looked at contained limited information about the management of risks to people from unsafe or inappropriate support. Assessments to mitigate risks, such as malnutrition and medication administration, were not always completed or in place.

We have made a recommendation about improving risk assessment to protect people from unsafe or inappropriate care.

People we spoke with told us they felt safe and comfortable at the home. Staff had safeguarding training to enhance their skills to protect people from potential abuse, inappropriate support or poor care.

We reviewed rotas and found staffing levels and skill mixes were sufficient to help people with a timely approach. The manager checked staff learning with competency testing and question sessions, which covered multiple areas including personal care, infection control and the MCA.

We noted staff gave people their medicines with a safe and patient approach. All the staff who administered medication received training and competency testing to underpin their skill and knowledge. One person said, “The staff are very effective, good with your medication.”

Staff promoted lunch as a sociable occasion and ensured a welcoming atmosphere during mealtimes. They documented people’s preferences and special diets, whilst frequently checking their weights and monitoring their health against any potential concerns.

During our inspection, we saw staff continuously asked people’s permission before they undertook any tasks. Staff had training and understood the principles of the Mental Capacity Act 2005 (MCA) and associated Deprivation of Liberty Safeguards (DoLS).

When we discussed the principles of good care, staff demonstrated a good level of awareness. This was enhanced by clear involvement of people and their relatives in their care planning. One person who lived at Marsh House told us, “Very nice staff. Yes, they’re kind and compassionate.”

The manager and staff worked hard to understand people’s backgrounds, preferences to care and how they liked to be supported. Care records we reviewed included their life histories to help employees gain a better awareness of each person.

People and staff said they felt the management team was visible about the home and the new manager was experienced and had good leadership skills. We saw records demonstrated action had been taken when the provider’s wide-ranging quality assurance systems identified issues.

During this inspection 13 December 2016, we found the provider had made improvements to meet the fundamental standards inspected and had an overall rating of Requires Improvement. We saw that significant work had taken place since our last inspection to improve the safety, effectiveness and quality of the service and found no breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. However we did find that the work being done was still in its early stages and needed to be sustained to ensure a consistent delivery of safe care and treatment that could be evidenced in the longer term.

As a result of the improvements made, the service has been taken out of special measures. The service will be expected to sustain the improvements and this will be considered in future inspections. You can see what action we told the provider to take at the back of the full version of the report.

During this inspection we reviewed actions the provider told us they had taken to gain compliance against the breaches in regulations identified at the previous inspections in July 2016 and February 2016. We also looked to see if improvements had been made in respect of the breaches.

Marsh House provides personal care for up to 33 adults. Nursing care is not available at this location. The home is situated in a rural area close to the towns of Chorley and Leyland.Some of the bedrooms have en-suite facilities. There is a large dining room, communal areas, hairdressing room and conservatory available for people living at the home. The grounds are well maintained with seating and patio areas. These are accessible for those who use wheelchairs and there was a stair-lift and passenger lift in the home. Public transport links are available and there are car parking spaces for visitors and staff. At the time of this inspection there were 23 people living at Marsh House

The service had a registered manager in post and they had been in post since April 2016. 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 and associated Regulations about how the service is run. The registered manager had notified the CQC of any incidents and events as required by regulation.

People who lived at Marsh house told us that they felt safe in the home and that there were sufficient staff available to help them when they needed this. People living and visiting the home spoke highly of the registered manager and told us they were happy with the care and treatment.

Since the last inspection in July 2016 a new pharmacy system had been introduced into the home and this had led to an improvement in the management of the medicines. Staff had also received medicines management training. Medicines were being stored and recorded appropriately including controlled drugs (medicines subject to tighter controls because they are liable to misuse). There were up to date policies and procedures in use by staff. Appropriate procedures were in place for the ordering and disposal of medicines.

We noted areas of good practice in relation to medicines management. We made some recommendations to support this continued good practice in that the registered manager sought guidance on documenting the removal of pain killing patches and on making sure that all the medicine administration charts (MARs) included details of the people’s allergy status. We also noted that sprays were not always kept by the person who used them. We recommended that this be risk assessed to help ensure that they can be accessed easily in an emergency.

We found that training records indicated that all staff had now had training on safeguarding people from abuse. All the staff we spoke with knew the appropriate action to take if they believed someone was at risk of abuse and were aware of the procedures for reporting bad practice or ‘whistle blowing ‘within the organisation. We saw that the registered manager had followed the service’s procedure effectively in regards to misconduct by a staff member.

We saw that all staff had completed a programme of induction training and that improvements to how the on going training of staff was managed had been made. Staff told us how they felt supported through supervision and training to fulfil their roles.

The level of staffing on the day of the inspection was sufficient to ensure that the current number of people living in the home had their needs met in a timely manner. The numbers of staff on shift during the day and night were seen to be consistent. Systems were in place for the recruitment of staff and to make sure the relevant checks were carried out before employment.

Since the last inspection the provider had been responsive and proactive in improving the systems used in the recording of information about people’s needs and the planning of their care. We looked at the risk assessments in place for people and these included risk assessments for skin and pressure area care, falls, moving and handling, mobility and nutrition and for the management of a different conditions or specific medication. We looked at the risk assessments in place and how people would be moved in the event of fire. These had been kept under review.

Care plans we looked at did not have information about any particular preferences at the end of their life. We have made a recommendation that the service took advice from a reputable source, about end of life training for care staff and on supporting people to express their views and decisions about their care, treatment and support at the end of life.

We saw that a range of organised activities were being made available to people and that staff had been actively involved in supporting people with activities that had been arranged. We also saw that a variety of meaningful activities had been planned for the Christmas period.

We noted that the environment within the home had not been developed to make it as enabling an environment as possible for people living with dementia. We made a recommendation about seeking guidance from a reputable source on adapting the home’s environment to support the independence of the people who were living with dementia.

We saw that there were systems in place to assess the quality of the services in the home. There was a programme in use to monitor or ‘audit ‘service provision to identify areas of weakness and address them.

The last inspection of Marsh House took place on 29 February 2016. At that time we found significant concerns in the service’s arrangements to safeguard people against the risk of; not receiving person centred care, inadequate nutrition and hydration, inadequate arrangements to identify potential risks in order to protect people from harm or injury, inadequate measures to assess and consider people’s consent to care, inadequate systems to identify or address issues that affected the quality of the service, poor medication management, lack of staff supervision and training, inadequate measures to deal with complaints and concerns and lack of governance and leadership.

The provider did not have suitable arrangements in place to ensure that staff were suitably qualified, supervised and competent to provide safe care and the provider was not notifying the Care Quality Commission of reportable incidents. As a result of our findings the service was put in special measures. Special measures ensure that providers found to be providing inadequate care, significantly improve and provides a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

As a result of our findings we ensured appropriate action was taken to keep people safe. We received from the provider an action plan on how they were going to meet the requirements of regulations Regulation 9 - Person centred care, Regulation 11 – Need for consent, Regulation 12 – Safe care and treatment, Regulation 13 – Safeguarding service users from abuse and improper treatment, Regulation 14- Meeting Nutritional and Hydration needs, Regulation 16 receiving and acting on complaints, Regulation 17 – Good governance, Regulation 18 – Staffing, and Regulation 20A – Requirement as to display of performance.

During this inspection we reviewed actions the provider told us they had taken to gain compliance against the ten breaches from the previous inspection in February 2016. We also looked to see if improvements had been made in respect of the additional shortfalls in people’s care we had identified. We found improvements had been made in respect of receiving and acting on complaints, sending notifications to the Care Quality Commission (CQC), reporting safeguarding incidents to the local authority, seeking people’s views on the quality of the service, and referring people to the local authority for deprivation of liberties authorisation.

Some minor improvements were noted with the information within people’s care files and seeking support from health professionals for people involved in accidents and falls. However, little in the way of improvements was found with respect to; managing medication safely, staff performance management, staff training , management of people’s risks from harm and risks of abuse and ill treatment, management of nutrition hydration, management of risks of infection and contamination, governance and quality assurance systems.

Marsh House provides personal care for up to 33 adults. Nursing care is not available at this location. The home is situated in a rural area close to the towns of Chorley and Leyland.

Some of the bedrooms have en-suite facilities. There is a large dining room, communal areas, hairdressing room and conservatory available for people living at the home. The grounds are well maintained with seating and patio areas. These are accessible for those who use wheelchairs and there is also a stair-lift in place. Public transport links are available and ample car parking spaces are provided.

The service had a new registered manager who had been in post since April 2016. This followed the departure of the previous manager who had been in post at the time of our inspection in February 2016. The registered manager was present throughout the 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.

The findings of this report relate to findings and evidence from March 2016 onwards when we had asked the provider to rectify the breaches in regulation.

At the time of this inspection there were 31 people who lived at Marsh House. We spoke with seven people living at the home, feedback varied due to some people having limited communication skills. We spent time observing care delivery and spoke with people who visited the service.

Some people told us that they felt safe and that they noticed improvements in the care however, some people told us things had got worse. They expressed that a lack of a consistent and regular staff team had impacted on the quality of care they had received.

People were not protected against avoidable harm. Quality assurance systems at the home had continued to fail in identifying and resolving associated risk in a timely manner, therefore exposing people to significant risk of harm and neglect. We communicated our concerns to the local safeguarding team after the inspection to ensure that risks were appropriately managed for one person we identified to be at significant risk of neglect.

We found people’s safety had continued to be compromised in a number of areas. This included how people’s medicines were managed, induction of new staff and temporary staff, how staff were supported to do their job through training and supervision, how risk assessments had been assessed and the guidance that had been provided to staff to reduce the risks, how emergency evacuation was planned and how people were protected from the risk of infections and contamination.

Mental capacity assessments were not always completed for people who lacked capacity to make specific decisions. Staff lacked knowledge and understanding of the mental capacity act and how people should be supported. For example, the provider had not ensured that people had best interest decisions meetings if they lacked capacity. We were told that people who had been assessed as lacking mental capacity were making unwise decisions and that this was not something the home could prevent or address, regardless of the fact they lacked capacity to understand what they were doing.

People’s health care needs had been assessed however, adequate risk assessments had not been developed to guide care staff. This placed people at risk of avoidable harm. Plans for safe evacuation of people had not been completed which meant people could not be assured safe evacuation during emergencies. This was the case for the most vulnerable people in the home.

Relatives told us people had been offered drinks and snacks. Especially people living with dementia and people at the end of their life. However risks of malnutrition, dehydration and personal hygiene were not sufficiently managed. People who could not eat in the dining room were left longer waiting for food. Choice was compromised by a directive by the service not to offer people a cooked breakfast after 10.30am. There were no goals in place for people who required food and fluid monitoring charts. Staff had recorded what people had drank however there was no evidence how they determined whether they had given people enough or what was a sufficient amount of fluids. This exposed people to risks of harm.

People told us they were treated with dignity and respect and we saw care staff speaking to people in a respectful manner. However, we observed incidents where people’s dignity was not supported. We raised concerns regarding the home’s ability to meet people’s needs. People had waited for up to one hour to use the toilet and staff could not toilet people because the hoist was faulty and there was no immediate replacement hoist. This had caused significant distress to people involved.

Evidence we saw showed the home had made efforts to involve people in decisions around the care they received. However, this was not consistent and had been undermined by lack of knowledge on mental capacity and consent within the home.

Feedback from relatives was mixed. Some people felt they had seen gradual improvements in the quality of care however some relatives informed us the quality of care had further deteriorated. Relatives felt the high use of agency workers had impacted the quality of care provided. They also felt the home could do with more staff as staff looked rushed at all times. We observed call bells were ringing for long periods of time without being answered. People had complained being left on the commode for up to 45 minutes. This had been reported to us before the inspection and had been investigated by the local authority safeguarding department.

There had been an attempt to improve management systems in the home however, we found on going concerns with quality assurance, audits and oversight. The systems were not robust and had not identified some of the concerns that we found.

Staff had not been effectively supported for their roles. There was no induction in place for care staff who were new to the home. This had exposed people to actual harm. There had been a number of safeguarding incidents involving agency staff which were attributed to lack of knowledge about people’s needs. There was no induction policy in place to ensure agency staff were made aware of people’s needs before they started their role. We found significant shortfalls in staff training and development. This was an on going concern which the home had failed to address and had impacted the quality of care that people received.

There was no robust infection control measures within the home. Staff were observed not following infection control measures throughout the day.

Marsh House provides personal care for up to 33 adults. Nursing care is not available at this location. The home is situated in a rural area close to the towns of Chorley and Leyland.

Some of the bedrooms have en-suite facilities. There is a large dining room, communal areas, hairdressing room and conservatory available for people living at the home. The grounds are well maintained with seating and patio areas. These are accessible for those who use wheelchairs and there is also a stair-lift in place. Public transport links are available and ample car parking spaces are provided.

The last inspection of Marsh House took place on 26 November 2014. At that time we found concerns in the service’s arrangements to safeguard people against the risk of inadequate nutrition and hydration and arrangements to identify potential risks, in order to protect people from harm or injury. The provider was not assessing and managing risks to people using the service and the provider was failing to effectively manage people’s food and fluid intake. As a result of our findings we requested the provider the provider to provide us an action plan on how they were going to meet the requirements of regulations 10, and 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which were in force at that time.

During this inspection we reviewed actions taken by the provider to gain compliance against the two breaches from the previous inspection in November 2014.We also looked to see if improvements had been made in respect of the additional shortfalls in people’s care we had identified. We found some improvements had been made in respect of choice meals and some environmental maintenance. However little in the way of improvements was found with respect to managing nutrition and hydration.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These included; –the provision of person centred care, the need for consent, providing safe care and treatment, safeguarding service users from abuse and improper treatment, meeting nutritional and hydration needs, receiving and acting on complaints, good governance, staffing, the lack of submission of notifications and the failure to display the rating from the last inspection in the service. You can see what action we have taken at the end of this report.

The registered manager was present throughout 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 and associated regulations about how the service is run.

At the time of this inspection there were 30 people who lived at Marsh House. We spoke with seven people living at the home, feedback varied due to some people having limited communication skills. We spent time observing care delivery and spoke with people who visited the service. People told us that they felt safe, however comments about a lack of staffing consistency infringed on the day to day experiences of care received.

We found that people were not protected against avoidable harm and quality assurance systems at the home failed to identify or resolve associated risk, therefore placing people at significant risk of harm and neglect. We communicated our concerns to the Local authority commissioning teams and ensured that the standard of risk management at the service was addressed by the provider before leaving the site on our first day of inspection.

We found people’s safety was being compromised in a number of areas. This included how people were assisted to eat and drink, how people were supported after experiencing falls, how well medicines were administrated and how staff were trained to support people after falls.

Staff were not always following the principles of the Mental Capacity Act, 2005 for people who lacked capacity to make particular decisions. For example, the provider had not ensured that people’s rights were actively assessed under the Mental Capacity Act or Deprivation of Liberty Safeguards, even though their liberty was being restricted.

We found that people’s health care needs were not appropriately assessed therefore individual risk factors had not been fully considered, placing people at risk of avoidable harm.

Although some people told us they felt safe and their privacy and dignity was respected, we saw that care was predominantly based around tasks and did not take into account people’s preferences. We were concerned that some very frail people living at the home were not treated in a dignified manner by some staff. There were significant concerns around staff attitude to people’s request for support at night time.

The staff did not consistently involve people in decisions made around the care they received. Care plans did not evidence involvement and observation of care confirmed concerns regarding standards of dignity and respect.

We received variable feedback from relatives; some expressed positive comments about the care provided whilst others were concerned about the high use of agency workers and inconsistency in effective communication between staff at the home.

We did not find evidence of robust management systems in the home and quality assurance was not effective in order to protect people living at the service from risk.

Staff were not provided with effective support, induction, supervision, appraisal or training. The provider did not have effective governance systems in place to ensure that improvements could be made.

We found people’s medicines were not safely managed. People were running out of medication at weekends.

We found the provider was not reporting serious injuries and allegations of abuse to Local Authority Safeguarding and to the Care Quality Commission which would have ensured appropriate oversight.

We found the service did not have effective systems to deal with complaints about care and treatment and found that the manager did not keep robust records or show how complaints were being responded to.

On our first day of inspection we found people were at extreme high of risk and harm. We required the provider to take some immediate actions to address the concerns we discovered. This included arranging for another manager to support the registered manager and making referrals to specialist professionals. On our second visit we found the provider had put together an action plan which they had started to work on. We found some risks to people had been reduced slightly however people continued to be at high risk of unsafe care.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

People told us they were happy with their care and support. Their admission to the home had been handled well and they had discussed the support they needed beforehand. One person told us, 'I was so lucky to get a bed here. When the hospital told me there was a bed available at Marsh House I could have run down here'.

We observed that staff interaction with people was very good. Staff engaged with them in conversations and asked people about and confirmed with them choices about daily routines and personal care.

We observed people in the home were relaxed around staff. They were able to express themselves freely and openly. People told us staff treated them well and they had no cause for concern. There were no rules to follow and no rigid routines.

People told us that staff supported them to manage and to take their medicines.

We saw the home was nearing the completion of a major refurbishment which had already improved the facilities and services available to people.