We undertook an inspection of Marion Lauder House on 11and 12 April 2017. The first day of inspection was unannounced which meant the provider did not know we were coming.

We last carried out an inspection at Marion Lauder House on 5 January 2016. We rated the service as requires improvement overall.

Marion Lauder House provides nursing and personal care and accommodation for up to 75 older people, some of whom are living with a diagnosis of dementia. There were 68 people living at Marion Lauder House at the time of this inspection.

The home accommodates people requiring nursing and residential care over two floors in three living units called Maple, Brookfield and Cherry. There is also a respite assessment unit that provides residential dementia care. At the time of our inspection the provider had recently renovated a bungalow in the grounds of the home and was using this for additional accommodation.

There was a registered manager in post at the time of this 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 registered manager had kept us informed of safeguarding incidents and other notifiable events which had occurred in the home in line with their statutory obligations. Staff were confident in describing the different kinds of abuse and the signs and symptoms that would suggest a person they supported might be at risk of abuse. They knew what action to take to safeguard people from harm. All of the staff received regular training that provided them with the knowledge and skills to meet people’s individual needs in an effective manner.

People’s safety risks were identified, managed and reviewed and the staff understood how to keep people safe. There were sufficient numbers of suitable staff to meet people’s needs and promote people’s safety.

We looked at medication administration records (MARs) on the nursing unit and on the respite unit. Records on the nursing unit were complete and accurate. Nursing staff were recording initials when administered and using the key code on other occasions, for example when PRN medicines were not required or if medicines were refused and destroyed. The recording of medicines on the respite unit was confusing and not always accurate. The manager provided evidence that this had been addressed.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the registered manager understood when an application should be made and was aware of the principles of the Mental Capacity Act 2005. Staff sought people’s consent before they provided care and support. However, some people who used the service were unable to make certain decisions about their care. In these circumstances the legal requirements of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) were being followed. Where people had restrictions placed upon them to keep them safe, the staff ensured people’s rights to receive care that met their needs and preferences were protected.

The environment was designed to enable people to move freely around the area of the home where they lived. There were lounges and dining areas in each unit of the home and a large activity room in a separate area of the home. This room was used to provide day care for a number of clients but it was also accessible to people living in the home if they expressed a wish to do so. There was also access to secure garden spaces from lounges on the ground floor . The physical environment of the home had undergone positive change and we saw that the residential unit in particular was stimulating and interesting for people with dementia.

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Marion Lauder House is registered to provide accommodation for up to 79 people who require nursing and/or personal care. The home is separated into five units. These include two nursing units known as ‘lounges’, a residential unit, a respite unit and day centre. The units are situated over two floors. All of the people residing at the home, and using the respite facility are living with dementia. At the time of our visit there were 18 people living in the residential unit and 35 people living in the nursing units. People are supported by two or three qualified nurses in a morning, reducing to two in the afternoon and eight care staff plus one activity co-ordinator throughout the day. This reduces to five care staff and one qualified nurse in the evenings and at night.

The inspection was unannounced and took place on 06 January 2016. The inspection was carried out by two adult social care inspectors, and a specialist advisor. Specialist advisors have up-to date knowledge and experience in their specialist area. The specialist advisor was a registered general nurse.

Prior to this inspection there had been a full inspection carried out on 18 May 2015. At that inspection we rated the service as inadequate and the service was placed into special measures.

This was because there were breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. The breaches were in relation to: inadequate assessment of people’s needs, care and treatment was provided without required consent, inadequate systems in place to manage risks and monitor the service, unlawful control and restraint, poor wound management and clinical practice, inadequate staff training and poor communication between nurses and other healthcare professionals which placed people at risk of harm. The home did not have a registered manager and so were not meeting the requirements of the law.

The purpose of special measures is to provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. At this inspection we found there was enough improvement to take the provider out of special measures.

The home had a manager registered with the Care Quality Commission (CQC) who was present on the day of the inspection. A registered manager is a person who has registered with 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 the last inspection we found there were no assessment of the needs and preferences for care and treatment for some of the people using the service. We also found records were out of date. At this inspection on 06 January 2016 we found improvements had been made although care records varied in the quality of information contained within them. We were made aware that new care plans were being introduced across the service and we saw these were more person centred. However care staff we spoke with were unable to understand the format of the nursing plans which meant they would not know where to look for information should they need it. To help ensure the health and well-being of people is protected, we recommend the provider looks for a best practice solution to ensure that all care records

reflect the care required in a format easily accessible to all staff.

We saw that procedures were in place to prevent and control the spread of infection and risk assessments were in place for the safety of the premises.

At the last inspection we found there were not enough suitably qualified, skilled and experienced staff working at the home. Since that inspection more staff had been recruited and we found people were cared for by suitably skilled and experienced staff that were safely recruited. Care staff received the essential training and support necessary to enable them to do their job effectively and care for people safely. Records showed that staff had also received training relevant to their role and further training was planned. The staff we spoke with had a good understanding of the care and support that people required. However we have recommended that, in order to be able to respond to people’s healthcare needs the Registered Mental Health Nurses (RMN’s) receive further training on wound care management.

At the last inspection we found some staff did not always respect people or treat them in a dignified way. We found improvements had been made, staff had received further training and interactions between staff and the people who used the service were good. Staff were polite and patient when offering care and support. The home had a calm, relaxed atmosphere. Staff responded quickly and efficiently when people became upset or agitated and used effective techniques to diffuse situations. There were a range of activities taking place and people had access to a full activity timetable if they wanted it.

We found that suitable arrangements were in place to help safeguard people from abuse. Guidance and training was provided for staff on identifying and responding to the signs and allegations of abuse.

At the last inspection we found that risks to people’s health and well-being had not been properly managed, such as poor nutrition and the development of pressure ulcers, and although plans were in place to help reduce or eliminate the risk it was not clear who had responsibility for maintaining these plans . We found people were placed at risk because changes in their healthcare needs were not escalated in a timely manner. At this inspection we found improvements had been made with the appointment of a clinical lead who had responsibility for ensuring care plans for people requiring nursing care were up to date and accurate.

We saw that food stocks were good and people were provided with a choice of suitable and nutritious food and drink to ensure their health care needs were met.

To help ensure that people received safe and effective care, systems were in place to monitor the quality of the service provided and deal with any emergency that could affect the provision of care.

Checks were made to the premises and servicing of equipment. Suitable arrangements were in place with regards to fire safety so that people were kept safe.

Staff were not fully able to demonstrate their understanding of the principles of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions. We found there was a breach in Regulation 11 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because the provider was not working in with the principles of the Mental Capacity Act 2005.

You can see the action we have told the provider to take on the back page of this report.

The inspection was unannounced and took place on 18 May 2015. The inspection was carried out by three adult social care inspectors, an expert by experience and a specialist advisor. Experts by experience are people who have personal experience of using or caring for someone who use this type of care service. Specialist advisors have up-to date knowledge and experience in their specialist area. The specialist advisor was a registered general nurse.

Marion Lauder House is registered to provide accommodation for up to 79 people who require nursing and/or personal care. The home is separated into five units Maple, Cedar, Cherry which are the nursing units, Brookfield which is the residential unit and there is also a respite unit. The units are situated over two floors. All of the people residing at the home, and using the respite facility are living with dementia.

At the time of our inspection there were six people staying in the respite unit, 12 people in the residential unit and 38 people accommodated in the nursing units. People were supported on the respite unit by three care staff during the day and one at night. This was the same on the residential unit. The nursing units were located on the ground and first floors. The nursing units were supported by six care staff, two or three nurses during the day and one nurse at night. There was also a deputy manager and a general manager who had recently been employed by the home. The registered manager had left and the general manager had been recruited to take over this role.

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 a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

The manager told us they were waiting for their Disclosure and Barring Service check to come back so they could submit their application to CQC to register. The Disclosure and Barring Service (DBS) helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable groups.

Prior to this inspection there had been an inspection carried out on 12 August 2014 where breaches in the Health and Social Care Act 2008 (Regulated Activities) 2010 were identified. The home sent us an action plan to tell us how they were going to improve. We had since then received a number of concerns from members of the public and health and social care professionals about the care and welfare of people residing at the home or using the respite service which we needed to look at during the inspection on 18 May 2015.

At the last inspection in August 2014 we found a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 because people were given medicine covertly without the correct safeguards being followed. At the inspection 18 May 2015 we found staff did not understand their responsibilities under the Deprivation of Liberty Safeguards (DoLS) and the correct processes were still not being followed. The Deprivation of Liberty Safeguards aim to make sure people in care homes are looked after in a way that does not inappropriately restrict their freedom. We found this was a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we followed up on action which was needed following the last inspection in August 2014 in relation to infection control. At the inspection on 18 May 2015 we found significant improvements had been made in relation to the cleanliness of the home and the décor in the communal areas of the downstairs nursing unit.

At the last inspection in August 2014 we found improvement was needed in relation to medicine management. At this inspection we found that medicines, including controlled drugs, were stored safely. We observed medicine being administered on two of the units and found most people received appropriate support to take their medicine. However on one unit we found the administration of medicine was impersonal and there was little or no verbal communication between the staff and the person being supported. We also found some medication was being given covertly without a proper assessment being done. This was a breach of Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the last inspection in August 2014 we found support plans and clinical notes were out of date and did not always reflect the person’s needs. At this inspection we found there was little improvement in the accuracy and continuity of clinical care records which meant some people were at risk of unsafe care and treatment. Care plans were still not person centred and assessments were not clear. This was a breach of Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found there was a breach of Regulation 9 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people did not experience person centred care specific to their needs.

Before the inspection we had received information of concern from visiting health and social care professionals and relatives of some people who used the service about the quality of support they received from some of the support staff and the qualified nurses. There were also concerns raised about whether there were enough staff to support the needs of people living at Marion Lauder House. We looked at staffing levels and training records and found improvement was needed. This was because people did not always receive care and support in a timely manner and clinical notes were not accurately maintained. This was a breach of Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us more staff were needed and the manager told us they were recruiting. The manager told us they were planning to open a new nursing unit which would be staffed within the current staffing levels. This was a concern to us as the current staffing levels were not sufficient to support the needs of all the people who currently used the service.

We spent time observing how staff interacted with people who lived at the home. We found some staff interacted well and knew about the people they were supporting. Other staff we found did not engage well with the people they were meant to be supporting . We found some staff were not clear about the correct way to move or handle people and had little or no regard for the dignity of the person they were supporting. We did observe some staff defusing situations which may have become challenging and demonstrating good practice within some areas of the home. We found there was a breach of Regulation 10 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people were not always respected or treated with dignity.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'. The service will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, it 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.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014.

The inspection was unannounced and took place on 12 August 2014. The inspection was carried out by two inspectors, pharmacist inspector, an expert by experience and a specialist advisor. Experts by experience are people who have personal experience of using or caring for someone who use this type of care service. Specialist advisors have up-to-date knowledge and experience in their specialist area. The expert by experience had personal experience relating to care homes and dementia care and the specialist advisor was a nurse specialising in cognitive behaviour and mental health.

We carried out an inspection on 13 May 2013 where no regulatory breaches were identified. A responsive inspection was carried out on 5 August 2013 following on from information of concern we had received. Again no regulatory breaches were identified at that time.

Marion Lauder House provides accommodation for up to 76 people who require nursing and personal care.  The home includes a dementia nursing unit which is located over two floors, a residential unit and a respite unit which are located on the ground floor.

We had received information of concern about the respite unit and the downstairs nursing unit. We found there were breaches of Regulations 9, 11, 12 and 14. You can see what action we have asked the provider to take at the back of the full version of the report.

At the time of our inspection 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 and has the legal responsibility for meeting the requirements of the law; as does the provider.

The registered manager told us they were aware of their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes.  The Deprivation of Liberty Safeguards aim to make sure people in care homes are looked after in a way that does not inappropriately restrict their freedom. We found improvement was needed to ensure the correct process was followed where an application had been made to DoLS and to ensure the process was supported by appropriate records.

We were able to access all areas of the home and noted there was a strong stale odour throughout the downstairs nursing unit and on the stairway. We found carpets on the stairs to be badly stained and the dining area on the ground floor nursing unit was dirty. Some of the toilets were in need of cleaning. We found there was a breach of Regulation 12. The provider made us aware of their refurbishment plan and we could see some areas had been redecorated. We saw the residential unit, the respite and the upstairs nursing unit were clean and tidy. We looked at three bedrooms and found them to be well presented and clean.   

The registered manager told us they had introduced a fixed staff team on the upstairs nursing unit in order to provide more continuity of care for the people who used the service. We received lots of positive feedback about this part of the service.

We found that medicines, including controlled drugs, were stored safely. However we found the homes medicines policies were not consistently applied across the home and that there was a lack of supporting personalised information about people’s individual medicines needs.

Support plans showed that people had access to their GP and other health and social care professionals such as; psychiatrists, dietician, district nurses and social workers. We found some information contained in the care files we looked at was out of date and did not always reflect the person’s needs. We spent time observing how staff interacted with people who lived at the home. It was apparent from our observations of the care staff throughout the day that the team were caring. We spoke with six members of staff who told us they enjoyed their job and were proud of what they did.

We had not always been informed by the registered manager of incidents and accidents which had occurred at the home through statutory notifications so we were unable to check whether appropriate action had been taken. A statutory notification is something all providers must send to us to tell us of incidents, accidents or deaths which have occurred within the home.

This inspection took place because concerns had been raised through the Manchester Safeguarding Unit about the way people were being looked after. In light of this we spent most of our time talking with the people who used the service and their relatives, and observing the way staff cared for the people who used the service.

People who used the service said they were happy with the care provided. One person said, “I am very happy here and the girls look after you well.” We observed staff speaking with people in a caring and respectful manner. One person was seen holding a staff member’s hand. They told us, “I like holding her hand, she’s lovely.”

Relatives of the people who used the service said they were happy with the care provided. One person told us, “The staff are nice people who always make you welcome”.

We observed the way lunch time was managed. People said they enjoyed the meals. People were supported with their meals as required. One of the people who used the service said, “The meal was good, but it always is.”

Relatives said they had never heard any staff speak inappropriately to any of the people who used the service. One person said, “I have absolutely no worries about my relative’s safety, they are extremely well looked after.” One of the people who used the service said, “The staff know what I like and they get it for you.” Another person told us, “I just shout and someone always comes.”

The people who used the service said they were happy with the way they were looked after. One person said, "I feel looked after, the staff are very nice." Another person told us, "The staff here are very nice they always ask you what would you like".

We spoke with a relative of one of the people who used the service. They described the staff as 'supportive and caring'. They said they were very happy with the care and said their relative was always well dressed. The relative confirmed they were involved in the development of their care plan.

A plan was in place for each person which provided details of the care they needed. Staff consulted with health care professionals such as district nurses and people’s GP for advice and guidance when necessary. This ensured people’s physical care needs were met.

People’s emotional care needs were met through a range of social activities.

Staff were trained on how to safeguard people from abuse. They were aware of the different types of abuse that could take place and the signs to look out for. None of the staff had any concerns about the safety and welfare of the people they looked after or the care practices of their colleagues.

The home's complaint procedure was available to the people who used the service and their relatives so they knew what to do if they were unhappy with the standard of care they received.

As part of this review we asked relatives to comment on the management of the home and the standard of care provided. We also asked Manchester city council, the Primary Care Trust (PCT) commissioning team and a visiting health care professional for their views of the service. Limited information was obtained from the people using the service due to communication difficulties. In light of this, we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. During the visit we saw positive interactions and engagement between staff and the people using the service to ensure they received the care and support they needed.

Relatives of the people using the service said they were very happy with the care provided. They said the staff were professional and affectionate towards the people living at the home. They considered the home was very well managed. Comments made by relatives included:

‘My wife is very well looked after. She is always kept clean and tidy as is her room. The staff know all of the peoples names, and I have often seen staff sitting with people holding their hand.’

‘I am very happy with the care. There is always a calm atmosphere in the home, although there are always plenty of activities. The staff are very affectionate towards the people living at the home.’

‘My relative is allowed to be herself. The staff know her little ways and she is treated with such dignity. The staff are lovely and very affectionate. They will hold her hand and give her a cuddle which I know she likes.’

‘The staff know everyones name, they are very approachable and friendly.'

'The staff are helpful, pleasant and professional. I have recommended this home to a few people and I am very happy my wife is there.'

‘The care is wonderful, I can’t fault the staff. The staff give my relative lots of time.’

‘Since the new manager has been working at the home, the staff seem to be more friendly towards the relatives. She is very keen and approachable and welcomes any comments. I think the management is excellent.’

‘The new manager is very good.’

The health care professionals we spoke with were happy with the way the service was being managed and raised no concerns. Both health care professionals commented on the improved management of the service. A visiting healthcare professional said, ‘Care plan notes are accessible and have improved over the last four months. They are well maintained. The content is person specific and you can see the involvement of the residents in the care planning.’

Manchester city council contract department said safeguarding referrals are being made appropriately and these are gradually reducing. This was put down to the improved management of incidents and overall improvement to the way the service was being run.

We spent the majority of our visit to the home on the nursing dementia unit, where 54 of the home's 78 residents lived. Most people receiving care on this unit were not able to give us direct feedback about their care. We spoke to one resident on the nursing unit and one resident on the residential unit. We also spoke to a relative who was visiting his mother. The relative we spoke to said he had no concerns about the standard of his mother's care, although he did inform us that she had been injured due to falls while she had been living at the home. The residents were complimentary about the home. One person said "it's a lovely home". The other said "I love it here, the girls are marvellous, they think about you". The resident we spoke to on the nursing unit commented that there were not always enough recliner chairs for everyone.