We carried out a review of the data available to us about Miranda House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Miranda House, you can give feedback on this service.
Miranda House is a residential care home providing nursing and personal care for up to 68 people. The service supports people living with dementia, mental health conditions, adults under and over 65 years of age. At the time of our inspection there were 29 people using the service.
Accommodation was provided on two floors accessed by stairs and a lift. People had their own rooms and access to communal areas such as lounges, dining rooms and a conservatory. There was a secure garden accessed from the ground floor.
People’s experience of using this service and what we found
People had their medicines as prescribed. Staff had been trained to administer medicines and had their competency checked. When people were prescribed multiple ‘as required’ medicines for the same health condition, guidance for what medicine to give first needed to be clearer. The registered manager took action during our inspection and told us they would review the prescriber’s instructions with people’s GP’s.
At our last inspection we found high numbers of safeguarding incidents between people living at the home. At this inspection the numbers of incidents had reduced, and the provider was taking action to improve dementia care and support. A new dementia strategy had been produced and the provider was providing training, guidance and additional support to staff to improve dementia care.
Risks to people’s safety had been assessed and management plans were in place. These were reviewed by nursing staff regularly. Where needed additional monitoring records were in place which had no gaps in recording. Property and equipment were serviced and checked for safety on a regular basis.
The home was clean and smelt fresh. Cleaning schedules were in place for staff to make sure all the home was cleaned regularly. Staff were seen to be wearing personal protective equipment safely and staff told us they had plenty of stock. Staff were testing regularly for COVID-19.
People were supported by enough staff. The provider used a dependency tool to calculate numbers of staff needed. Some feedback we heard was that at times staffing was a challenge. The registered manager told us when staff called in sick at short notice it was not always possible to get agency staff. The provider told us they were reviewing deployment of staff to make sure they had the right staff role doing the right work.
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. Visitors were welcomed and there were no restrictions on visiting arrangements. Relatives were able to visit when convenient to them or if they wished they could book a visit in advance.
Staff enjoyed working at the home and people told us they felt safe and happy to be at Miranda House. Staff had training on safeguarding, and all told us they would report any concern.
Quality systems were in place and there were different levels of quality checks taking place. The provider had good oversight of the home and had improved ways in which learning was cascaded following incidents and accidents. Complaints received were logged and monitored by the provider until resolved.
Since the last inspection there had been changes in management both with the home manager and deputy manager. There was a new registered manager in post who was making changes to improve outcomes for people. Some staff did not appreciate the new management approach which had impacted on morale. However, we observed staff working together as a team and some staff told us they viewed the changes as a positive for the home.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 15 November 2021).
Why we inspected
The inspection was prompted, in part, due to concerns received about the provider’s approach to visiting, responding to concerns and risk of a closed culture. A decision was made for us to inspect and examine the concerns across a range of Caring Homes services.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Miranda House is a care home providing personal and nursing care to 31 people aged 65 and over at the time of the inspection. The service can support up to 68 people. Accommodation is provided on two floors accessed by stairs and a lift. The service has a secure garden people can access from the ground floor.
People’s experience of using this service and what we found
People had an individual risk management plan in place which was reviewed regularly by staff. We observed improvement was needed to two records to accurately record action needed and action taken to mitigate risks.
Recording of incident management had improved which meant incidents were being shared with the local authority and CQC as required. Staff had reviewed individual incident forms to make sure immediate action had been taken. Not all incidents had been discussed in the provider’s clinical governance meetings which meant further monitoring had not taken place.
People had an up to date behaviour support plan in place where needed to give staff guidance on how to support people experiencing distress. Whilst this was in place there were still high numbers of altercations amongst some people living at the service. The provider was taking action by providing specialist training to staff and working with the local authority. The provider had a new dementia strategy which they were starting to implement at the service.
People and relatives told us they thought people were safe at the service and well cared for. Staff had been provided with training on safeguarding and understood their responsibility to report any concern. Staff told us they were confident any concern would be addressed, and action taken. Staff had been recruited safely and there were enough staff on duty to meet people’s needs.
People had their medicines as prescribed and prescribers reviewed medicines regularly. Medicines administration records reviewed were completed accurately and had no gaps in recording.
People were living in a clean home and staff had cleaning schedules to make sure all areas were kept clean. All visitors had to complete a Lateral Flow Test and have their temperature taken prior to entry. Personal protective equipment (PPE) was available to visitors and bins provided to dispose of it safely.
People and staff were being tested regularly for COVID-19; any positive cases were discussed with the local public health protection team. Staff had been provided with training on COVID-19 and how to work safely. We observed staff were wearing the appropriate PPE at all times. The provider carried out infection prevention and control audits regularly to monitor cleanliness and safe working.
Management of the service had been inconsistent, and a new interim manager had been employed prior to this inspection. The regional manager and clinical lead provided consistency and were available to people, relatives and staff. Meetings had been held with people and quality surveys had been sent to people and relatives for their views. Actions in response to feedback had not always been taken which the interim manager told us they would address without delay.
Staff morale had improved, and staff told us they really enjoyed their work. People and relatives were very positive about the care provided and the staff approach. Staff worked in partnership with various healthcare professionals to make sure people’s needs were met.
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 30 March 2021) and there were three breaches of regulation. We served the provider requirement notices for two breaches of regulation and a Warning Notice for the breach of regulation 12. We returned to carry out a targeted inspection on 24 May 2021 to check compliance against the Warning Notice. We found improvements had been made and the provider was no longer in breach of regulation 12.
Why we inspected
We carried out an unannounced inspection of this service on 25 February 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve their governance systems and processes.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Miranda House on our website at www.cqc.org.uk.
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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Miranda House is a care home providing personal and nursing care for up to 68 people, some of whom live with dementia. At the time of our inspection there were 35 people living at the service. Accommodation was provided over two floors accessed by stairs and a lift. People had their own rooms and there were communal areas such as a conservatory and lounges for people to use. The home had a secure garden accessed from the ground floor.
People’s experience of using this service and what we found
At our last inspection we found people were at risk of harm as the provider had failed to put in place a robust, safe system to manage incidents. At this inspection this had improved, and the provider had an oversight of incidents and accidents. Incident forms were being completed and action taken recorded. Reflections for learning were taking place to prevent reoccurrence and analysis of incidents had been carried out to highlight themes and patterns. Relevant agencies had been notified where appropriate about serious incidents and safeguarding concerns.
People who experienced distress reactions were better supported by staff who had been trained and given guidance and support. The provider had organised training for staff to help them gain skills in personal safety and conflict management. Senior management had been available to offer staff guidance and talk about strategies. People’s behaviour support plans had been reviewed so their current needs were recorded with clear strategies for staff to follow.
People were being supported by staff who wore personal protective equipment (PPE) safely. There were supplies of PPE available to staff and training on how to use it had been provided. Staff had additional rest rooms available so they could socially distance whilst on breaks. People and staff were being tested for COVID-19 following government guidance. No cases of COVID-19 had occurred for a number of months.
The environment had been re-decorated and looked brighter and fresh. Flooring had been replaced and new furniture had been bought. The service looked clean throughout and staff told us they cleaned high contact areas regularly. There had been no new admissions recently, so the isolation area was not in use.
Visiting from relatives was welcomed if booked in advance and planned. This enabled visiting areas to be thoroughly cleaned. Visitors were screened prior to admission and asked to carry out a Lateral Flow (LFT) test, which is a rapid result test for COVID-19. Visitors were also asked to wear PPE whilst at the service.
The provider kept managers and staff up to date with guidance through regular meetings and communications. Any updates were shared with people and relatives using email and newsletters.
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 30 March 2021). The provider completed an action plan after the last inspection to show what they would do and by when to improve.
Why we inspected
We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.
CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Miranda House is a nursing home for up to 68 older people some of whom live with dementia. At the time of our inspection there were 48 people living at the service. Accommodation was provided over two floors which are accessed by stairs and a lift. There were various communal facilities such as dining rooms and lounges. There was a garden for people to access from the ground floor.
People’s experience of using this service and what we found
Incidents and accidents had not been managed safely or effectively to identify causes and work to prevent reoccurrence. Incident forms were not always completed, reviewed or followed up to make sure action was taken. We had not been notified of all incidents and events as required by law.
Staff had not been provided with training they needed to carry out their roles safely. There were a number of people living at the home who experienced distressed reactions which lead to behaviour that challenged the service. Staff were not able to consistently support people safely and had experienced incidents of physical aggression.
Quality monitoring systems were not effective in assessing and monitoring the quality and safety of the service. Not all injuries had been investigated to determine causes which meant action could not be taken to mitigate risks or to make sure relevant agencies were informed. The provider did not have an accurate oversight of the service to make sure it was able to monitor and mitigate risks.
Since the last inspection there had been changes in management at the home and on a regional level. This had caused a period of instability which had affected communication with relatives and staff.
Staff told us there were not always enough of them working on the first floor of the home. When staff were asked to carry out 1-1 work this had impacted on how the shifts were managed. We have made a recommendation about staffing numbers.
One area of the home had been identified for new people moving in to enable a period of isolation to reduce the transmission of COVID-19. We found this was not being used safely as staff had not moved people out of this area to their permanent rooms following their period of isolation. The provider took action during the inspection to address this unsafe practice. Prior to moving into the home people were tested for COVID-19 and only able to move in when results were negative.
People were living in a clean environment overall but there were areas of the home that required redecorating and updating. The provider had commenced decorating the ground floor and planned to complete the first floor. We were told new furniture had been ordered for the home.
Staff had the required personal protective equipment (PPE) available to them and were seen to be using it safely. Staff had been given training on how to use the PPE and on working safely during the pandemic.
Visiting was permitted but had to be pre-booked with the home. This enabled staff to support visits safely. A breakdown in communication had resulted in relatives not being able to visit at a weekend, the provider told us they would address this without delay.
The home was carrying out the required testing for COVID-19 as per the government guidance. This included people living at the home and the staff working there. Vaccinations for COVID-19 had commenced.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 27 November 2019).
Why we inspected
The inspection was prompted to seek assurances about the safety and care of people following information received as part of ongoing safeguarding concerns and a police investigation. As investigations were ongoing this inspection did not examine the circumstances of those incidents. We undertook a focused inspection to review the key questions of safe and well-led only.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Miranda House on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to providing safe care, management and provider oversight and failing to notify CQC of notifiable incidents at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We met with the provider following our site visits and will continue to 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Miranda House is a nursing home for up to 68 older people. Most of the people living at Miranda House live with dementia. Accommodation is on two floors which are accessed by a lift. There were communal areas on each floor including lounges and kitchen areas. The home has a garden which people can access on the ground floor. At the time of our inspection there were 55 people living at the service.
People’s experience of using this service and what we found
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, however, the documentation for recording assessments of mental capacity were not always clear. We discussed this with staff who told us the provider was reviewing documentation. We have made a recommendation about recording best interest processes.
The provider’s pre-admission assessment tool had not always been completed in full when an assessment had been carried out. This meant we could not be sure all of people’s needs had been assessed. However, there was supporting documentation from other agencies collected as part of the pre-admission assessment.
People were cared for by staff who had been trained and were supported in their roles. Mealtimes had improved since our last inspection, but further work was needed to support people with meals in their own rooms. People were supported to choose their meal when sat at the table which was effective for people with dementia. Kitchen staff had a good overview of people’s dietary needs and met regularly with care staff to monitor people’s weights.
Where a referral was needed to a healthcare professional, staff did this in a timely way. Local GP’s visited weekly or sooner if needed and staff communicated people’s needs effectively. Staff had handovers with each other and daily meetings to make sure all staff were up to date with people’s needs.
All relatives we spoke with at Miranda House were very positive about the care and support provided. They thought the service was safe and there were sufficient staff available to help. We observed there were enough staff on duty and reviews of staffing rotas confirmed this was consistent. People were supported by staff who had been recruited safely with required checks carried out by the provider. Risks had been assessed and there were management plans in place to give staff guidance on action to take. Medicines were managed safely with nursing staff taking responsibility for administration.
People had been involved in their care and were cared for by staff who were kind and caring. We observed many positive interactions with people and staff that demonstrated staff knew people well. Information on people’s background had been collected and shared with staff so they knew who people were. Relatives were welcome at any time and many brought their dogs in for people to interact with.
People had their own personalised care plan which recorded all their needs. Care reviews were held regularly, and care plans updated when needed. Where people required additional monitoring, this was carried out and care delivered was recorded in people’s files. Activities were provided and planned with people and relative’s involvement. The home had a mini-bus which was used to take people out into the local community. People’s end of life care needs were recorded and many people had chosen to stay at Miranda House until the end of their life.
There was a new registered manager who had made many improvements. People, relatives and staff all told us the registered manager was approachable, visible and listened to everyone. There were meetings for people, relatives and staff which were held regularly. People’s views were sought, and surveys carried out. The registered manager took action to improve the service in response. Quality monitoring was in place and the provider had a good oversight of this service. Complaints were logged and monitored. The service had received many compliments about the care provided at Miranda 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 requires improvement (published 10 December 2018) and there were three 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. We have made one recommendation in the key question Effective.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Miranda 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.
Miranda House accommodates 68 people in one purpose built building. On the first day of the inspection, there were 54 people living at the home. The home was registered to support people living with dementia and their nursing needs, over the age of 65 years.
People’s bedrooms were located over two floors. Each floor had a separate lounge, ‘quiet’ lounge, a dining room and adjacent kitchenette. Bedrooms had en-suite facilities and there were communal bathrooms and toilets. There was a central kitchen and laundry room.
There was 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. The registered manager was available throughout the inspection.
This service has a poor history of compliance, as this was the third time the service had been rated requires improvement. At the last inspection in July 2017, two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. These had not been fully addressed, which meant at this inspection, there were two repeated breaches and an additional breach in regulation.
The provider had a range of action plans to improve the service. Much of the work was “in progress”. The action plans did not consistently give specific timescales for the work to be completed. This did not enable development to be “kept on track” or monitored to ensure sufficient progress was being made. The plans covered areas such as the environment, person centred care, care planning and the development of social activities. Additional support and resources had been allocated to the implementation of the action plans.
Risks to people’s safety were not being properly identified and addressed. For example, water from a hand wash basin in a communal toilet was excessively high and there were locks on bedroom doors that were unsafe to use. These were addressed once brought to the registered manager's attention. There was a trailing lead, which a person precariously stepped over and a heater in the dining room that had protruding edges, which increased the risk of injury if fallen against.
Medicines were not safely managed. Information about “as required” medicines was limited and staff were crushing some medicines without the prior approval of a pharmacist. Information was not sufficiently detailed or up to date regarding medicines to be taken covertly. Covert medicines are when medicines are disguised in food or drink, without the person’s consent or awareness.
The environment was not conducive to people’s dementia care needs and did not promote good infection control. The layout of the home did not enable easy orientation and there was limited signage or points of interest to assist people when moving around. Items such as skirting boards and some furniture was chipped. This did not enable the surfaces to be properly wiped to be hygienically clean. The provider told us they had recognised improvements to the environment were needed and were taking action to address this.
Staff did not always have a clear understanding of people’s needs. For example, staff did not sufficiently support a person who was agitated and a lunch time meal was chaotic, due to its lack of organisation. Records did not always show challenging behaviour was effectively managed.
There were sufficient staff to support people. There was a staff presence in communal areas and staff had time to sit and chat to people. There were positive interactions and staff spoke about people with fondness.
People had access to a range of health care professionals and had enough to eat and drink. Food was generally cooked “from scratch” and a varied menu was in place. Attention was given to any weight loss and specialist advice was gained as required.
There was a focus on going out and links with the community were being developed. People could use the home’s minibus.
Staff had been safely recruited and received a detailed induction. They felt supported in their role and had undertaken a range of training deemed mandatory by the provider. Staff worked well as a team and were willing to learn and develop. They were aware of their responsibilities to identify and report a suspicion or allegation of abuse.
We identified two repeated breaches and a third breach 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.
They are registered to provide accommodation which includes nursing and personal care for up to 68 older people, some of who are living with dementia. At the time of our inspection 50 people were using the service. The bedrooms were situated over two floors. There were communal lounges and dining areas with satellite kitchens on each floor with a central kitchen and laundry. People also had access to a communal garden on the ground floor.
We undertook an unannounced focused inspection of Miranda House on the 28 and 29 November 2017 This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in July 2017 had been made. The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This is because the service was not meeting some legal requirements.
No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going 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
At the last comprehensive inspection in July 2017 we identified the service continued to be in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not being stored at the correct temperature. During this inspection we found that these improvements had been made and medicines were being stored safely.
Some areas of medicines management required further improvement. Monitoring systems in place for the safe administration of medicines had not identified gaps in recording. Photographs of people using the service at the front of medicine administration records (MARs) had not all been updated and some photographs were missing. Decisions to administer medicines covertly to some people had not been regularly reviewed.
Some areas of the home had damaged paintwork which made them difficult to clean. Poor cleanliness in clinical was rooms was observed during our inspection. We have discussed this with the regional manager and registered manager. They said there was a renovation plan in place for the new year which would address the areas of infection control we had identified. They also took some immediate action during our inspection to resolve some of the damaged areas. Staff had access to appropriate protective equipment, such as disposable gloves and aprons to protect people with the prevention and control of infection.
Risks to people’s safety were assessed and guidance on how to minimise these risks was put in place for staff to follow. Processes were in place to safeguard people from abuse. However, staff’s understanding of safeguarding and what constituted abuse was not always consistent. Staff were aware of their responsibility to report concerns.
A dependency tool was in place to assess the level of staff that were required. The service's
staff rota demonstrated the assessed levels of staff had been provided, with cover being filled by staff completing extra shifts or the use of temporary agency staff. Safe recruitment practices were being followed.
The provider regularly assessed and monitored the quality of care provided. However, quality assurance systems had not always identified the shortfalls highlighted in this inspection.
Feedback from people and their relatives was encouraged. The registered manager and regional manager had identified improvements that were needed in the service and had plans in place to implement them.
Systems were in place for staff to report accidents and incidents. The registered manager reviewed these reports and recorded any actions that were necessary following them. Lessons were learned following incidents and reduced the risk of an incident re-occurring.
We have not changed the rating of the service at this inspection. We found on this inspection the provider had not taken the actions required to make the necessary improvements for those areas that had been identified as requiring improvement at the previous inspection but did not fall within in the regulation breach.
This inspection took place on 13 and 14 July 2017 and was unannounced.
At the last comprehensive inspection in September 2016 we identified the service was not meeting Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not being stored at the correct temperature and some tablets had not been disposed of before their expiry date. The provider wrote to us following the last inspection to say they would take action to address the management of medicines by November 2016. During this inspection we found that these improvements had not been made and medicines were still not being stored safely. This was a continued breach of the regulation.
The registered manager had identified that work was needed in relation to storage of medicines and had raised this repeatedly through the provider’s reporting processes. Despite this being identified as a breach of regulation at the last inspection, the provider had not ensured that action was taken to store medicines within the safe temperature range. Whilst the quality assurance systems had identified shortfalls, the process to ensure those shortfalls were rectified when the work required additional expenditure or building works was not effective. This had resulted in people using the service being placed at risk of receiving medicines that had been compromised and were not effective.
We observed some positive interactions between staff and people using the service. Generally staff were friendly and the atmosphere was calm and relaxing. We heard staff singing with people and laughing with them. However, we observed some occasions when staff did not respond to people’s request for support and reassurance.
Relatives gave mixed feedback about the staff. One said “The managers and the carers are all lovely. They’re very caring and loving to me and my relative. They’re like my extended family, I love them all”. Comments from other relatives included “Some carers are lovely, absolutely wonderful, but others are a bit iffy” and “It’s not the Ritz, but I keep my relative here because of certain care staff who are lovely”.
Staff were taking suitable action when they identified that people did not have capacity to consent to their care or treatment and had made applications to authorise restrictions on people’s liberty. Where restrictions had been authorised with conditions, the registered manager had reviewed the actions they had taken to meet the condition.
Risks people faced were being well managed. Staff had identified risks people faced and had planned with them how those risks should be managed. Staff had a good understanding of the risks and the action that was planned. The plans were regularly reviewed and updated when people’s needs changed.
People’s records contained care plans relating to their specific needs and there was evidence that the plans were updated when people’s needs changed. People and their relatives told us they were involved in developing and reviewing their plans. Where people were not able to tell staff what care they needed, there was a record of who had been involved in making decisions.
Staff told us they received training and support which gave them the knowledge and skills needed to do their job effectively. Comments included “I did the Living in my world training a few weeks ago; it was about putting ourselves in the shoes of people we care for. It was really good” and “I’m doing the Care Certificate”. Nurses said they had access to professional development in order to meet their registration requirements.
Staff generally spoke highly of the registered manager. Comments included “If I speak to the manager about anything, she’s always there and will listen. She takes the time to listen” and “Our manager is excellent, always on hand to listen”. One member of staff said “The manager is better than she used to be, she’s more supportive and tries to sort problems out”.
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 this report.
At the last comprehensive inspection in October / November 2015 we identified that the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because risks people faced were not managed effectively, there were not always sufficient staff deployed in the home, the home did not always follow the requirements of the Mental Capacity Act 2005 when people did not have capacity to consent to care and treatment. In addition, care plans did not always contain up to date information about people’s specific needs and records kept by staff were not always accurate. We served warning notices to the provider and registered manager as a result of some of the concerns we identified. We completed a focussed inspection in June 2016 and found that the provider had taken the immediate action necessary to improve the service. During this inspection we found that the provider had sustained these immediate improvements, but further work was needed for people to receive a consistently good service.
People were given the support they needed to take medicines they had been prescribed and staff kept good records of the medicine they had supported people to take. Although medicines were stored securely, further work was needed to ensure they were always stored at the temperature recommended by the manufacturer and were disposed of before they reached their expiry date.
Staff were taking suitable action when they identified that people did not have capacity to consent to their care or treatment and had made applications to authorise restrictions on people’s liberty. However, where restrictions had been authorised with conditions, staff were not always clearly recording the actions they had taken to meet the condition.
Risks people faced were being well managed. Staff had identified risks people faced and had planned with them how those risks should be managed. Staff had a good understanding of the risks and the action that was planned. The plans were regularly reviewed and updated when people’s needs changed.
Staffing levels had been reviewed and there were sufficient staff deployed to meet people’s needs. During our observations we saw that staff were available to provide support to people when needed. This included support for people to eat, drink and move around the home safely. Requests for assistance from people were responded to promptly. Staff told us there were enough of them available to be able to provide safe care and meet people’s needs. Comments from staff included, “There are enough staff to meet people’s needs, which is a big improvement”, “The team works well together and there are sufficient staff to meet people’s needs” and “Staffing levels are enough to provide the care that people need”.
There was an improvement in the information set out in people’s care plans. People’s records contained care plans relating to their specific needs and there was evidence that the plans were updated when people’s needs changed. Some people told us they were involved in developing and reviewing their plans. Where people were not able to tell staff what care they needed, there was a record of who had been involved in making decisions.
People told us they were treated well and staff were caring. Comments included, “I am very happy living here. Staff treat me well” and “The staff are kind and look after me”. We observed staff interacting with people in a friendly and respectful way. Staff respected people’s choices and privacy.
Staff told us they received training and support which gave them the knowledge and skills needed to do their job effectively. Comments from staff included, “Training is good quality. Every week we complete some training”, “The online training courses are good” and “I have had lots of e-learning and training. This has helped me to understand people’s needs”.
Staff felt the changes that had been made to the management of the service since the last comprehensive inspection had been positive. Comments from staff included, “Morale is much better. We continue to make improvements and everyone has worked together”, “There have been further improvements (since the last inspection). Management are there when you need them and they will come onto the floor if we need help. People are getting good care” and “It’s enjoyable now to come to work. When I leave I feel I have done a good job”.
We found a breach 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 this report.
This unannounced inspection was carried out to assess whether the provider had taken action to meet the warning notices we issued. We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notices have been sustained, to assess whether action has been taken in relation to the five requirements made at the last inspection and provide an overall quality rating for the service.
This report only covers our findings in relation to the warning notices we issued and we have not changed the ratings since the inspection in October and November 2015. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. You can read the report
from our last comprehensive inspection by selecting the 'all reports' link for Miranda House on our website at www.cqc.org.uk.
At this inspection we found that the provider had taken action to address the issues highlighted in the warning notices. Risks people faced were being effectively assessed and managed. Staff had clear information about the support people needed. They demonstrated a good understanding of people's needs and the support that was required to keep people safe. Staff were following the actions listed in the risk assessments and kept clear records of the care and support they provided.
The service was meeting the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff had taken appropriate action when they assessed that people did not have capacity to make a decision. Staff had completed additional training in the MCA and DoLS and demonstrated a good understanding of the principles of the Act. People’s care records contained detailed and decision specific mental capacity assessments and the provider had made DoLS applications to the local authority where appropriate.
Miranda House provides accommodation and nursing care for up to 65 people with complex dementia needs and at the time of the inspection there were 63 people accommodated. At the previous inspection the home was found to meet the standards inspected.
This inspection was unannounced and took place on 13, 16 and 21 October 2015 and 17 November 2015
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.
People did not receive their care and treatment in a safe way. Risk assessments were devised for people at risk of falls, for people at risk of developing pressure ulcers (sometimes known as bed sores)and for people at risk of malnutrition. Action plans to mitigate the risk were not followed by the staff. For example, pressure ulcer dressings were not assessed according to the tissue viability wound management plan.
People were not protected from safe medicine management. Medicine Administration Records (MAR) were not signed by staff when medicines were administered. Accurate records of the stocks held were not maintained and the temperature of the room where medicines were kept was above the acceptable range. People were prescribed a combination of anti-psychotic and medicines for agitation and to induce sleep. For some people these medicines could cause people to fall over causing harm and injury.
People were at risk from the spread of infection. Bins with lids were not provided in bathrooms, food was taken from the kitchen and from dining rooms to people’s bedrooms uncovered. Staff were not using appropriate boards to prepare breakfast and were using the same utensils to spread butter and jam on people’s toast. On our return visits we found some improvements in where staff prepared meals and we saw staff using lids on meals being taken to people's bedrooms.
People did not benefit from consistent staff supervision. Some staff did not always interact with people in a positive manner. We saw staff speak to people without eye contact or not giving the support to reduce people's levels of anxiety. We saw people entering and leaving other people’s rooms and consistently walking the corridors. Interest points were not provided and memory boxes that helped people find their rooms were empty.
Staff did not show a clear understanding of the principles of the Mental Capacity Act (MCA) 2005. For example, there was family involvement for best interest decisions when they did not have the authority to make these decisions. Consent was gained from a relative to deliver personal care to one person who refused personal care. Guidance was not provided to staff on how to manage situations when people became aggressive or violent towards staff attempting to deliver personal care.
Best interest decisions were made by staff without first assessing people’s capacity to make these decisions. Some people were placed at higher risk of falls by best interest decisions that were made. For example, taking walking aids away from a person in bed to maintain clear pathways in the event the person got out of bed.
The care plans in place were not up to date and did not reflect people’s current needs. For example, we saw people with injuries but care plans had not been developed to manage the wound. We found intervention charts which should be used to monitor the effectiveness of the care plans were not completed as required. Daily reports were not consistent with the intervention charts. Staff had documented for some people a good intake of fluid but the intervention charts showed the fluid intake was below the recommended fluid intake.
Records were not completed accurately and in a timely manner. We saw staff recording that they had checked people at 30 minutes intervals. However the record was completed three hours later. Medicine Administration Records (MAR) were signed to show fortified drinks were administered twice daily although the stocks in place showed they had not been administered.
Quality assurance arrangements were place to assess people's safety and wellbeing. However, medicine audits had not identified poor stock control systems and the poorly ventilated medicine room.
New staff received an induction and attended training needed to meet people’s specific needs. For example dementia awareness. Staff were supported with their roles and responsibilities. Staff with lead roles such as nutrition and End of Life had the training needed to undertake additional roles. One to one meetings where staff discussed concerns, personal development and performance took place with their line manager.
Safeguarding adult’s procedures were in place and staff attended the training which helped them identify the signs of abuse. Members of staff knew the signs of abuse and the responsibilities placed on them to report suspected abuse. Some relatives said their family member was safe living at the home.
People had a choice of meals at mealtimes and snacks were provided between meals. Fortified meals were provided to people at risk of poor nutrition. The chef consulted with people on their likes and preferences.
People were supported with their ongoing health. GP visits were arranged and people had regular optician check-ups. People were referred to healthcare professionals for specialist input. For example social workers, tissue viability nurse specialist and psychiatrists.
Activities coordinators organised activities, entertainment and outings. However, a limited number of people were benefitting from outings and activities. The activities coordinator interacted well with people and showed they had a good understanding of people’s background. We also saw some staff interacting well with people and showed they had insight in the causes of some behaviour. For example, how previous employment impacted on behaviours.
Relatives knew a complaints procedure was in place and felt confident to approach staff with complaints. The registered manager investigated complaints and responded in writing to the complainant on the outcome of complaints investigations.
The views of relatives on the standards of care at the home were sought by the home through surveys. Three responses were received and they gave positive feedback on the care and treatment their family member received. The action plan from the surveys was to improve the questionnaires used to seek feedback on the delivery of care and treatment.
We conducted another visit on the 17 November 2015 and the staff we spoke with said there had been improvements since our previous visits.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report.
The overall rating for this service is ‘Inadequate’ and the service is 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.
A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?
Below is a summary of what we found. The summary describes what people using the service, their relatives and care workers told us, what we observed and the records we looked at.
If you want to see the evidence that supports our summary please read the full report.
This is a summary of what we found;
Is the service safe?
We found the service was safe. People's relatives told us they felt people were safe. One said "I think this is a very safe home". Another said "yes they are safe. I am confident in the staff". Care workers had been trained in safeguarding vulnerable adults and were aware of their responsibilities. The service had a comprehensive policy on safeguarding and raised alerts with the appropriate authorities.
People received safe and appropriate care, treatment and support. Care was planned and delivered so that people were safe. Appropriate risk assessments were carried out and regularly reviewed.
We found that there was sufficient numbers of appropriately trained care staff on duty to support people. Care workers received training in a range of subjects that included moving and handling, safeguarding vulnerable adults and dementia care. Care workers we spoke with told us they had received the training and felt confident they could provide care and support to people.
The service did not have anyone subject to a Depravation of Liberty Safeguards (DoLS) application. This is where a person can be deprived of their liberties for their own safety. We spoke to the registered manager and they were aware of the recent Supreme Court judgement in relation to the Deprivation of Liberty Safeguards and were taking appropriate action.
They told us the organisation had a DoLS advisor who gave training and updates regarding DoLS. We saw they were booked to visit the service in June 2014 to inform staff on the latest Supreme Court judgement and what this meant for the service. This meant that the provider understood their responsibilities under the Mental Capacity Act 2005.
Is the service effective?
We found the service was effective. Some people at the home had complex needs and we saw that their needs were being met effectively. For example, one person was at risk of weight loss. They had been assessed and appropriate measures put into place to reduce this risk. This included nutritional supplements in their diet. We saw they were monitored regularly and weighed weekly. The records showed that this person had gained three Kilograms since January 2014. We also observed that other people were supported and encouraged to eat and drink and were offered meal choices and extra portions.
Care workers were able to tell us about the needs of the people they supported. For example, one person had mobility difficulties and needed hoisting for all transfers. Care workers were able to tell us this person could become anxious and needed constant encouragement and reassurance. This reflected the guidance in the care plan. This showed us that people received effective care.
Is the service caring?
We found the service was caring. Relatives we spoke with told us they thought the service was caring. One said "they are definitely well looked after here". Another said "my father is well cared for and he seems happy". During the SOFI observation we saw that people were given choices, supported to make decisions and care staff took time to understand people where they had communication difficulties. Throughout our inspection the atmosphere was pleasant and we observed many interactions between care workers and people that were caring, relaxed and friendly.
Is the service responsive?
The home was responsive. People's needs had been assessed before they moved into the home, regularly reviewed and reflected in the care plans. We saw evidence that care workers recognised when a person's condition changed or their health had deteriorated and sought the help and advice of other professionals. For example, we saw that appropriate referrals to GPs, falls clinic and occupational therapists were made.
Complaints were dealt with in a timely fashion in line with the provider's policy. The service also took account of people's comments. For example, it was raised at a relative's meeting that the glass in picture frames could be a safety hazard. The service was in the process of replacing the glass in frames with Perspex.
Is the service well led?
We found the service was well led. A registered manager was in post and was visible around the home. We saw they were approachable and available to people, relatives and staff. During our inspection we looked at the quality assurance systems that were in place. The information reviewed demonstrated that the service was monitored on a consistent basis to ensure that people experienced safe and appropriate support, care and treatment. This also included regular surveys involving people, relatives, stakeholders and staff.