This inspection took place over three days on 30, 31 January 2018 and 02 February 2018 . The first day was unannounced, which meant the service did not know in advance we were coming. The second and third days’ were by arrangement.

Mariana House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Mariana House is registered with CQC to accommodate up to 23 people. At the time of this inspection, 16 people were accommodated and the home had seven vacancies. Mariana House is a large detached property. It has two lounges, a dining area, and a large garden. It has bedrooms on both the ground floor and first floor with lift access.

Mariana House benefits from a long standing registered provider/manager. 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.

At this inspection, we found a new breach of Regulation 9 and a continued breach of Regulation 17 in respect of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have also made two recommendations in respect of equality and diversity and end of life care.

Since our last inspection of Mariana House, we acknowledged the registered provider/manager had made improvements in the key questions of ‘safe’ and ‘effective.’ However, this is the third consecutive rating of ‘requires improvement’. The expectation would be that following the previous ‘requires improvement’ rating, the provider would have ensured the quality had improved and attained a rating of either 'Good' or 'Outstanding' at this inspection. This had not been the case so we plan to meet the registered provider to seek further assurance as to how they are going to address the issues identified in this report and ensure that it improves. Additionally, we will return to the home again in due course to review progress.

Staffing levels at Mariana House were sufficient to meet people’s needs and the home benefited from a stable workforce.

Systems and procedures which sought to protect people from abuse were in place and staff were able to describe the homes alert process for safeguarding and whistleblowing.

Safe systems were in operation for the management of medicines including ordering, storage, administration and disposal.

All relevant health and safety and building maintenance checks had been completed and safety certificates were up to date. Equipment used for moving and handling people had been serviced and maintained in line with regulations and was deemed safe to operate.

People were protected by the prevention and control of infection. The home was visibly clean throughout and there was no malodour present.

People living at Mariana House were cared for by staff who were well trained and competent to carry out their roles. All new staff were required to complete the Care Certificate and ongoing training was provided face to face via a professional training provider.

Staff treated people with compassion and dignity and respected their privacy. We saw people were afforded time to express their needs and communication was at an appropriative level and was not rushed. Staff talked to people with kindness and offered an appropriate level of encouragement and support.

People were well supported to eat and drink and to maintain a balanced diet. People were offered a wide range of menu options throughout the week.

People and their loved ones were not always involved in decisions related to their care and support and we found the quality of reviews to be poor with little or

Mariana House is a residential care home in Whalley Range in south Manchester. The home is registered to provide care and accommodation for up to 23 people. At the date of our inspection there were 19 people living in the home, all of them women. Mariana House is a large detached property. It has two lounges, a dining area, and a large garden. It has bedrooms on both the ground floor and first floor. The bedrooms have washbasins but no ensuite bathrooms.

This inspection took place on 4 and 5 January 2017. The first day was unannounced, which meant the service did not know in advance that we were coming. The second day was arranged on the first day of our inspection.

At the previous inspection in November 2015 we had found breaches of four regulations, and judged that the service required improvement. We issued two warning notices, in relation to two of the breaches.

Those five breaches at the last inspection related to the storage and recording of medicines, assessment of risks, obtaining of consent, timeliness of care planning, and quality monitoring systems. At this inspection we found that some improvements had been made in all these areas, although there was still room for improvement, as set out in the full report. The warning notices related to failure to assess correctly and implement advice regarding dietary needs, and secondly to failure to operate effective audits, in particular of care plans and medication. We found that sufficient improvement had been made in these two areas.

The registered service provider is also the registered manager, and has been registered as manager since 2011. He was not present during this 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 service had appointed a manager on 30 August 2016, who was present during the inspection. They told us it was their intention to apply to become registered manager. We refer to this person as “the acting manager” in this report.

There had been an incident in October 2016 when someone living in Mariana House had walked out of the building and been found in a neighbouring road. Action had been taken to prevent a recurrence and the home had co-operated with the local safeguarding authority. However, the person’s care plan and risk assessment had not been updated after the incident. We judged there had been a breach of the regulation relating to assessing risks.

In September 2016 a person suffered a mini-stroke, and there was evidence that it had not been recognised from symptoms earlier in the day, resulting in a delay calling the ambulance. This was a breach of the regulation relating to reducing risks to people’s health and safety.

There was information about people’s mobility in their care plans but there was no immediately accessible information for the fire service in the event of an emergency. The acting manager created a file of emergency evacuation plans during our inspection.

The layout of the building was safe for people to move around, with the exception of one doorway. We also saw furniture creating an obstacle in a corridor at one point.

We checked on the ordering, administration and storage of medicines and found that it was much better than at the previous inspection. The provider was now meeting the regulation in relation to the management of medicines.

Staffing levels were constant and met the needs of people living in the home. There had been little recruitment recently which created some pressure on the staff rotas. When people were recruited, safe recruitment methods were used, although we have made a recommendation that the application form should be updated.

Accidents and incidents were recorded but there was no analysis

An inspector visited this service on the 8 August to carry out an inspection. At our last inspection in May 2013 we had concerns that a notification of abuse was not reported appropriately. We also noted that improvements were required of the arrangements in place for staff supervision and appraisals. Prior to our visit we looked at all the information we hold on this service to help us to plan and focus on our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

During this inspection we spoke with two relatives, three care staff, the deputy manager and the manager. We spoke with four people who lived at Marianna House. We also looked at records and spoke with a visiting health professional.

Is the service caring?

Our observations showed us people were treated with respect and patience and two relatives told us they were happy with the care and support provided. One relative told us; “This is a really lovely place and I’m not worried about (my family member) at all.”

Is the service responsive?

We saw documentation which showed us people were referred to other health professionals as appropriate. We spoke with three care staff who gave examples of how they responded to changes in people’s needs and wishes and one relative told us; “This is an example of proactive care. They monitor people very carefully so if there are any problems they pick them up quickly.”

Is the service safe?

At our last inspection in May 2013 we had concerns that a notification of abuse was not reported appropriately. During this inspection we were informed of an incident that we considered should have been reported to the appropriate authorities and to the Care Quality Commission (CQC.) We concluded that improvements were required to ensure that incidents were appropriately identified and reported.

We found improvements were also required to ensure the environment was safe and suitable for people’s needs. For example we noted there were no window restrictors in place on some upper floor windows, a fire risk assessment required updating and there was no pictorial or visual signage to support people to move independently around the home.

During the inspection we noted information within two of the care records we viewed was incorrect. It is important that records contain up to date and accurate information so staff are able to give safe and effective care to people who live at the home. We concluded improvements were required in this area.

We found that the majority of people living in Mariana House were not able to communicate effectively due to dementia or similar conditions. Those who were able to express themselves indicated that they were satisfied with the care they were receiving. We observed the care offered by staff, especially at lunchtime, and found a warm and caring atmosphere within the home.

We were able to speak with a small number of people who lived in the home. One person told us: "Things are good here. I have nothing to complain about." Another person said of the staff: "They're very good. I'm well looked after. If I want anything I've only got to ask. They try to get it for me."

One relative said, about their mother: "Her care has been exemplary. We're delighted with it. The care has been over and above what I would have expected." "The ethos is about providing the best for her. She is perfectly securely safely and warmly looked after."

We found that the food provided was appropriate and varied.

We found that an incident of alleged abuse had not been promptly reported. The member of staff concerned was no longer working at the home.

We also found that the system of staff supervision had lapsed and there was no system of staff appraisal.

The maintenance of records had improved since the previous inspection.

During our inspection we spent sometime speaking with three people living at Mariana Hose, three visitors and a visiting healthcare professional. We also spent time observing people’s routines and how staff provided care and support.

We saw that people living at the home appeared relaxed and well cared for. Staff interactions were patient and respectful. Some of the comments people made included, “It’s very family friendly”, “I like the staff, they are very caring” and “It’s a good home”.

People visiting the home told us that they were happy with standard of care and support their relative received. They told us, “The staff are so patient”, “They [the staff] are very helpful and welcoming to visitors”, “The staff are so respectful” and “They [the staff] offer lots of encouragement”.

During the afternoon of our visit, an entertainer was visiting the home. They provided a music quiz and games. People were actively involved and appeared to be enjoying the interaction. Those people who did not wish to be involved were able to spend time in a quieter lounge.

The visiting health professional told us, “I feel they provided a good standard of care” and “We work well together, they are always in contact if they need anything or have any concerns”.

Visitors also told us they had no hesitation in speaking with the provider or deputy manager. We were told, “They are very helpful, nothing is too much trouble” and “We’ve never needed to complain about anything”.

People using the service told us that they were well cared for and supported by staff at Mariana house. They spoke positively about the food provided, the standard of accommodation and the services provided generally. A visitor to the home told us the management and staff of the home communicated well with them. Staff told us that the training and support provided to them enable them to meet the care and support needs of people safely and competently

The inspection took place over two days, on 20 and 24 November 2015. The first day was unannounced, which meant the service did not know in advance that we were coming. The second day was by arrangement.

The previous inspection had been on 8 August 2014, when we found that the service was failing to meet four of the legal requirements we looked at. The four areas were: reporting safeguarding incidents, unsuitable premises, assessing and monitoring the quality of the service, and record keeping. We found that these four areas had a minor impact on people living in Mariana House, and asked the provider to send us an action plan stating what action they would take to meet those requirements. We received the action plan on 17 November 2014. During the current inspection we checked to see whether this action plan had been implemented and whether the service was now meeting legal requirements in those areas. Our findings are set out in our full report.

Mariana House is a residential care home situated in the Whalley Range area of Manchester. The home provides care and accommodation for up to 23 people. At the date of our inspection there were 18 residents. Mariana House is a large detached property. It has two lounges and a large garden. It has bedrooms on both the ground floor and first floor. The bedrooms have washbasins but no ensuite bathrooms.

The registered service provider is also the registered manager, and has been registered as manager since 2011. 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.

We found that people felt they were safe in Mariana House. We saw that medicines were stored securely, but that the cabinet for controlled drugs did not meet the legal requirements for safe storage of these medicines. We also found that records of medicines administered were not always accurate, and that the recording of controlled drugs was confused. We also found that medicines had run out on one occasion because they had not been ordered on time. We found there were no instructions for staff about when to administer ‘as required’ medicines. These issues were a breach of the regulation relating to the safe management of medicines.

We found there were no instructions for staff about when to administer ‘as required’ medicines.

We found that the risk of injury from someone rolling from their bed onto a mattress had not been identified or mitigated, and this was a breach of the regulations relating to assessing and reducing risks.

Staffing levels were adequate, although one member of staff suggested they could do with extra help at busy times. Bank or agency staff were not used.

Staff were well-informed about safeguarding vulnerable adults and knew what to do if they witnessed or suspected any abuse. Recruitment records showed that pre-employment checks were carried out for people applying to work at Mariana House.

There were two staff trained as infection control champions. The electrical appliances were regularly maintained.

People told us they enjoyed the food and we saw the mealtimes were pleasant. Most people’s dietary needs were met.

However, we were concerned that recommendations by a hospital professional were not being followed for one person with specific dietary needs, who was at risk if the recommendations were not followed. This was a breach of the regulation relating to reducing risks.

Consent forms were not in use to record that people consented to the care and treatment they received. This was a breach of the regulation relating to obtaining consent.

Staff including the registered manager had not had training on the Mental Capacity Act 2005 (MCA). We did not see any mental capacity assessments. Two applications had recently been submitted under the Deprivation of Liberty Safeguards (DoLS).

Staff training was delivered mainly by one external trainer. Staff received regular supervision although we saw this was used to provide additional training.

There was access to healthcare professionals. The environment was comfortable but lacked provision for people living with dementia. We have made a recommendation that the provider should research ways to improve the physical environment for people living with dementia.

People living in Mariana House and their relatives were very positive about the care they received. We saw a homely atmosphere and encouragement for people to interact with each other. Staff were patient and respected people’s dignity.

Mariana House supported people nearing the end of their lives. We had received a letter from a relative commending the home on its care for someone who had died there. Two people who were near the end of life were being cared for well.

People and their families were involved in the process of planning their care at the time of their admission. Care plans were thorough although not always specific to the individual’s needs. However, we saw an example where a care plan had not yet been created, and another where the care plan did not reflect the person’s needs. These failings were a breach of the regulation relating to person-centred care. Care plan reviews took place.

There were activities available and people participated when they wanted to. Residents’ meetings took place and the views they expressed resulted in changes. There had not been any questionnaires recently for families, but they were encouraged to express their views informally.

There had been no complaints recorded since 2011.

Families and staff expressed confidence in the leadership of the registered manager.

Staff told us they felt well supported by the registered manager and the deputy manager. There were regular staff meetings.

Following our last inspection audits of medication and of care files had been introduced. Two monthly medication audits had been missed, and we were not confident that the issues concerning the safe administration, ordering and effective recording of medicines that we found would have been identified by the audits if they had taken place. The system for auditing care files was in need of improvement, as it did not show what areas had been looked at. Other audits were not being done. We found there was a continuing breach of the regulation relating to assessing and monitoring the quality of the service.

Events were notified to the CQC as required, except for some accidents which should have been reported as serious injuries.

In relation to the breaches of Regulations you can see what action we told the provider to take at the end of the full version of the report.