We undertook an unannounced inspection of Marlfield Care Home with Nursing on 12 and 13 December 2017. When the service was last inspected in October 2016, one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. This related to failings in the safe management of medicines. The provider wrote to us in December 2016 and told us how they would achieve compliance with the regulation. During this inspection we found some improvements had been made, but some areas of practice required further improvement.

Marlfield Care Home with Nursing is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is able to accommodate up to 74 people. At the time of the inspection there were 70 people living at the service.

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.

Although we found improvements in medicines management since our last inspection, further improvements were required. During the inspection we found that where people had PRN (as required) medicines, for example paracetamol, guidance around when and why to administer these medicines could be improved. In addition to this, we found within one care record a person had fallen and no update to the person’s care records or risk management guidance had been completed in their care plans.

People were positive about the care they received and spoke highly of the staff that supported them. People’s relatives also commented positively on how safe they perceived the service. Staff understood local safeguarding procedures and how to escalate complaints both internally and externally. People’s risks were assessed and managed, and staff understood and applied risk management measures. Staffing levels met people’s needs and recruitment was safe. The equipment and environment was subject to servicing and testing. Infection control guidance was followed and the service was clean.

People received effective care with the use of nationally recognised tools and guidance. People and their relatives spoke positively about care provision. Staff understood the protected characteristics of the Equality Act 2010 and told us how they applied it to their work. Staff received induction, ongoing training, supervision and appraisal. Clinical staff received support in their development and training. People were supported with their nutritional and hydration needs. People had access to healthcare professionals to meet their ongoing health needs.

People were supported by the adaptation and design of the service. Staff were following the principles of the Mental Capacity Act 2005, however we found practice in relation to decision specific capacity assessments and best interest processes required improvement. We have made a recommendation to the provider about this. The service had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. People can only be deprived of their liberty so that they can receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005.

People told us staff were caring and supported them in a kind and compassionate way. We made observations to support this. People’s relatives were mostly positive about the care provided in the servi

The inspection took place on 17 and 18 October 2016 and was unannounced. Marlfield Care Home with Nursing is registered to provide accommodation, personal and nursing care for up to 74 people, some of who are living with dementia. The service is split into a nursing unit and a residential wing each occupying two floors of the service. At the time of the inspection there were 72 people living there.

The service had a registered manager. 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. Although in post part-time since February 2016 the registered manager had been absent from the service for part of this time and only became the full-time registered manager of the service with effect from 03 October 2016.

Arrangements were in place for the safe ordering, storage, management, administration and disposal of people’s medicines. Although processes to check people’s medicine records had been completed on the residential unit, they were not sufficiently robust to ensure people always received their medicines as prescribed; for example, in relation to the usage of body maps to guide staff in the application of people’s topical creams.

Staff understood their role and responsibilities to safeguard people from the potential risk of abuse.

There was a system to assess, manage and minimise risks to people. Staff were knowledgeable about the risks to people and how these were to be managed.

There was mixed feedback regarding whether there were always sufficient staffing numbers deployed. Although some people perceived there were insufficient staff; evidence demonstrated there were sufficient staff to meet people’s care needs safely. There was a heavy reliance on regular agency staff to cover staff rosters. Further work was required to assure people and their relatives that sufficient staff were always deployed.

Staff had undergone relevant recruitment checks. The provider had not always sought an explanation for gaps in applicant’s employment history and the registered manager was aware of which staff needed to provide this information. Work was underway to address this for people, but more time was required to complete this work.

Staff underwent a suitable induction to their role. The registered manager had identified that staff had not all undergone the level of on-going training or supervision required by the provider. This was in the process of being addressed. Further time was required to complete this and for the registered manager to be able to demonstrate staff had consistently received the required level of training and supervision.

Staff spoken with were able to demonstrate their understanding of the Mental Capacity Act (MCA) 2005 and its use in their daily work with people. Not all staff had been able to update their MCA knowledge and arrangements were in place for staff to complete this training. Staff had correctly identified through the use of MCA assessments who was being restricted of their liberty and therefore required an application under the Deprivation of Liberty Safeguards (DoLS).

Lunchtime was a pleasant experience and people enjoyed their food. Processes were in place to monitor people’s weight and this information was used to manage people’s weight loss. Work was required on the residential unit to ensure checks on people’s fluid charts and their fluid records were sufficiently robust to identify if they were not receiving sufficient fluids for their needs. Although people were able to change their mind about their choice of main meal and they received a meal of their choice; sufficient consideration had not been given as to how the system for people choosing meals met the needs of people living with dementia.

Staff arran

We considered our inspection findings to answer questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well led?

At the time of this inspection the home was accommodating 41 people. We spoke with three people who use the service and three relatives. We also spoke with the manager and two deputy managers, an assistant unit manager, three of the nursing staff, five care staff, an activities coordinator, kitchen and domestic staff. We looked at care records for seven people who use the service. This is a summary of what we found –

Is the service safe?

We saw that care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. For example, there were detailed assessments of the risk of falls and appropriate planning to minimise the potential risk. This included regular reviews of falls, post fall monitoring and prompt referral for medical attention in the event of a suspected injury.

We saw that medicines were kept safely and appropriate arrangements were in place in relation to the recording of medicine. Staff received training to give them the knowledge and skills they needed to safely handle and administer medicines to people.

Our previous inspection of 5 and 6 June 2013 found that there were not always enough qualified, skilled and experienced staff to meet people's needs at all times. We judged that this had a minor impact on people who used the service. The provider wrote to us and told us the measures that would be taken to address the issues. During this visit the manager confirmed that staffing levels had increased since the last inspection and we saw this was reflected on the rotas. Staff we spoke with said that they had noticed improvements with increased staffing levels.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one. The manager was aware of recent changes to the legislation and was awaiting further guidance from the provider organisation.

Is the service effective?

The home had a Practice Development Nurse, whose role included promoting high standards of care and the development of competent and confident nurses, by providing clinical supervision and skills analysis for nurses.

Staff were provided with training and relevant qualifications through a combination of on-line computer and face-to face learning. Staff confirmed they had opportunities to attend regular training courses. This included dementia awareness training for the domestic staff as well as the care staff. Staff we spoke with demonstrated a good knowledge of the needs of people with dementia who were using the service.

People were provided with a choice of suitable and nutritious food and drink and were supported to be able to eat and drink sufficient amounts to meet their needs. We saw that nutritional risk assessments were carried out each month. Where the risk assessment identified that the person was losing weight there was prompt referral to external professionals for guidance and support. A person using the service told us they had as much as they wanted to eat and drink and that staff encouraged them to eat well.

Is the service caring?

We saw that care plans were person-centred. For example, one care plan showed that the person liked tea and a particular type of biscuit. We observed that the person was offered these biscuits and when they did not want the cold drink they had been served, staff offered to make them a cup of tea. In the care plans there were sections about peoples’ lives, including their life histories and those things that were meaningful to them.

A person’s relatives confirmed that staff were attentive and caring about the person’s needs and wellbeing. They told us they had been involved in developing the care plan and staff acted on the information they had given, in order to help their relative feel as settled and at home as possible.

A person using the service told us that staff treated them well. Another person told us “This is a good place to live” and said that the service was meeting all their needs. Another person’s relative commented positively about the service and said they “Couldn’t fault it”. They told us “I am always welcomed” and “They offer me a cup of tea”.

Is the service responsive?

Peoples’ health care needs were monitored and responded to. We observed that a care worker noticed that a person had some soreness around their eye and alerted the nurse. Care records showed that people were appropriately referred to external professionals when there was any concern about their well-being.

Procedures were in place for reporting accidents and incidents, including a system for monitoring falls. New shoes had been purchased for a person using the service who had been prone to falls. This showed that learning from incidents took place and appropriate changes were implemented.

The manager said that staffing numbers were adjusted on a day-to-day basis to ensure that there were sufficient staff to respond to peoples’ needs. They gave an example of when there had been an outbreak of infection in the home and additional staff were brought in to cover sickness. The manager also said that if someone was receiving end of life care the service ensured there was an additional staff member to sit with them and provide comfort and support.

Is the service well led?

There were effective systems to regularly assess and monitor the quality and safety of service that people received. Regular audits of the service took place and were recorded. Action plans were developed and followed to address any issues identified during the audits.

We saw evidence of consultation with and involvement of people’s families and representatives. The home had recently conducted a survey of peoples’ views about aspects of the service. The results indicated that the majority of the 36 people who had responded were satisfied with the overall service provided. There was also a system in place to monitor and respond to any concerns or complaints about the service. A relative told us “I feel I can raise any concerns”. Regular staff meetings took place. For example, a nurse’s meeting in March 2014 included discussion about safe practice in relation to aspects of handling medicines.

At the time of this inspection there was no registered manager. The current manager had applied for registration.

In this report the names of two Registered Managers appear who were not in post and not managing the regulatory activities at this location at the time of the inspection. Their names appear because they were still Registered Managers on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individuals names from our register.

People using the service told us staff always checked with them whether they were happy to receive care. People confirmed that staff respected their wishes and that they could refuse care if they wanted to. People told us staff provided the care and support that they needed. One person told us: “Staff provide the care I need.” Another person said: “Staff are kind and helpful." During the visit we saw examples of good staff interactions with people who used the service, for example, responding to requests for assistance and providing sensitive support to eat and drink.

Some people expressed concerns about unpleasant odours in the home and we found that the home was not cleaned effectively. We also found that the provider did not always listen to the concerns that people raised and take action to resolve the problem. We have told the provider to take action to address these concerns.

During the visit we spoke with six people who used the service. People told us they received the care that they needed from staff that had the right skills. Comments included, “very satisfied” with the care provided, “staff come quickly when I call them” and “staff are kind and treat us well”.

We observed staff interacting with people in a friendly and respectful manner, taking time to respond to questions. Staff offered people choices and explained what was happening, for example, what the lunch options were and what activities were taking place.

People we spoke with said they felt they were well treated by staff. People said staff maintained their dignity and asked them how they wanted their care to be provided. People gave examples of being able to choose where they had their meals and the support they needed for moving and transferring

People said they received the care they needed in the way that they wanted it to be provided. Some people said that although they received the care they needed, they sometimes had to wait for staff to be available.

People we spoke with said they felt safe in the home and were confident that staff would respond appropriately to any concerns they raised.

Most people we spoke with said they thought there were sufficient staff available when they needed them. People gave examples of staff responding promptly when they used their call bell and not being rushed. Three of the eight people we spoke with said there were not always enough staff available, saying they sometimes had to wait for staff to become available to receive the support they needed.

We spoke with six people who used the service and four relatives, four nursing staff, two care staff, the manager and deputy manager. People we spoke with confirmed that the service was meeting their needs. One person said: “It’s very good. I’m very impressed”. One person’s relatives said: “We are amazed at the carers. They do care and they are conscientious”. People also said that the staff kept the home clean. We saw that action had been taken to ensure that people were cared for in a clean, hygienic environment.

People who we spoke with confirmed that staff were responsive to their needs and said they had no complaints. However, other evidence did not support this. Robust arrangements were not in place to ensure that there were enough qualified, skilled and experienced staff to meet the health, safety and welfare needs of people using the service at all times.

People and their relatives told us that they felt the management listened to them and responded appropriately. One person’s relative told us: “Whatever you bring up the manager will listen and act upon”.

In this report the name of a Registered Manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still Registered Manager on our register at the time of this inspection. We have advised the provider of what they need to do to remove the individual’s name from our register.