We carried out an inspection of Marple Lodge Care Home on the 12 and 13 June 2018, the first day of inspection was unannounced.

Marple Lodge Care Home 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 home is situated in Marple, Cheshire and is registered to provide accommodation for up to 19 people who require personal care and support. At the time of inspection 17 people were living at the home.

The home was last inspected in November 2016 when it was rated as requires improvement overall and in four domains, safe, effective, responsive and well-led. During that inspection we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment, need for consent, good governance and staffing, specifically the lack of training provided.

Following the inspection, the provider sent us an action plan which explained the improvements they intended to make to ensure the home met legal requirements and improved the key questions, safe, effective, responsive and well-led to at least good. This inspection was carried out

to check improvements had been made and review the homes rating.

At this inspection we found improvements had been made and the service was meeting all regulatory requirements, although we have made two recommendations in relation to capturing people or their legal representative’s involvement in care planning and reviews and the planning and documenting of activities.

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.

Since our last inspection, a new registered manager had commenced working at the home. They had started in November 2017 as acting manager, becoming registered with CQC in April 2018. The registered manager was supported by a deputy manager, who had worked at the home under the previous manager and so provided consistency.

Each person we spoke with told us they felt safe, and enjoyed living at Marple Lodge. Relatives were also complimentary about the standard of care provided. We saw staff had received training in safeguarding, which was refreshed in line with the providers policy and staff spoken with knew how to report concerns. The home had appropriate safeguarding policies and reporting procedures in place and had submitted notifications to the local authority and CQC as required.

We found the home to be clean with detailed cleaning checklists and appropriate infection control processes in place. Staff wore personal protective equipment (PPE) to prevent the spread of infection and toilets and bathrooms contained hand hygiene equipment and guidance.

Both people using the service and staff we spoke with told us enough staff were deployed to meet needs. The home used a system to determine safe staffing levels, which we saw tallied with the rotas. This system was regularly reviewed to ensure it was accurate and reflected the current needs of people living at the home.

We saw medicines were stored, handled and administered safely and effectively. All necessary documentation was in place and had been completed consistently. The home’s quality monitoring procedures, had highlighted any gaps or omissions in medicines documentation and steps had been taken to address this. Staff responsible for administering medicines had been trained and had their competency assessed.

Staff spoke positively about the support and training provided. We saw staff had completed an induction programme upon commenc

This inspection was carried out over three days on the 22, 23 and 24 November 2016. Our visit on 22 November 2016 was unannounced.

At the last inspection on 16 and 23 February 2016 we rated the service as Inadequate' which meant the service was in ‘special measures.’ At that inspection we identified ten regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014, which related to safeguarding, safe care and treatment, meeting nutritional and hydration needs, staffing, person-centred care, the need for consent, dignity and respect and good governance.

Following the inspection the provider sent us an action plan which stated the breaches would be addressed by May 2016. This inspection was to check improvements had been made and to review the ratings.

Marple Lodge Care Home is a care home that is registered to provide accommodation and personal care for up to 19 adults. On the three days of our inspection there were 15 people living at the home.

The home is situated in a quiet residential area of Marple, close to local amenities.

The home had a manager registered with the Care Quality Commission (CQC), who was present throughout the three days of 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 and associated regulations about how the service is run.

During this inspection, we found significant improvements had been made and we observed staff giving positive and caring support to people. However, we also identified some areas where improvements were still required. The registered manager and the senior carer were responsive to our feedback and had started to take actions to make some of the required changes during our inspection.

During this inspection, we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some medicines were not managed safely for example we found there was not always clear, detailed written directions for the use of medicines to enable staff to apply topical prescribed creams. We did a medicine count for a particular medicine for one person and we found discrepancies in the number of tablets that has been signed as given and the total number remaining in the box. This meant there was a risk that prescribed creams and medicines may not have been applied when required, which could have resulted in unnecessary discomfort for the person.

In addition we saw that the covert medication policy was not being appropriate adhered to for one person receiving their medication covertly. Covert medication is the administration of any medical treatment in a disguised form. This usually involves disguising medication for example by administering it in food and drink. As a result, the person is unknowingly taking medication.

From looking at the training record and speaking with staff, we found improvements had been to ensure staff were properly trained. However, we found there were still some gaps in staff training. For example, we found one cook and care staff who served meals and prepared drinks and snacks for people had not received food hygiene training. This meant that the registered provider had not ensured staff had the qualifications, competence, skills and experience to meet the needs of people receiving a service and that practices at the home reflected up to date best practice guidelines.

The registered manager told us that short-term plans of care were not implemented for individual short-term needs such as a chest or urinary tract infection. This meant there was a risk that the care need may not be appropriately met. However during the inspection we did not see anybody who required a short term plan of care and we were given assurances that these would be implemented as and when required.

Staff spoken with

This inspection was unannounced and took place on 16 and 23 February 2016. During the previous inspection in October 2014, we found required improvements had been made. However, during this inspection we found those improvements had not been sustained.

Marple Lodge is registered to provide accommodation and personal care for up to 19 adults. On the two days of our inspection there were 16 people resident at Marple Lodge. Care was provided in either single or double rooms some with en-suite and there are communal bathrooms on both floors of the home.

The home had a registered manager and a manager who was intending to register. 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.

We identified 10 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.

There had been no routine checks of the building. There were no water temperature checks, fire tests had not been regularly carried out and emergency lighting checks had not been done since September 2015. The window restrictor in a first floor bedroom was broken and the window could be fully opened. There was equipment left by fire doors and in some areas the carpet was frayed. This meant the provider could not be sure the service was safe.

People's risk assessments were either missing or not fully completed. Medication records had some missing signatures. Some MAR's and care records did not contain a photograph of the person. This would make it difficult for new staff and agency staff to identify the person they were administering medication to. Some people's medication was not being administered as prescribed. One person had allergies to certain medication, which staff had not documented on their MAR’s, which meant they could be administered medication, which could cause them harm.

There were enough members of staff to keep people safe, although staff said an extra member of staff would enable them to spend more time with people. Staff training, supervisions and appraisals had not been completed for over a year.

There were two incidents recorded which should have been referred to the local authority under safeguarding which had not been done.

Mental capacity assessments had not been carried out. The provider had applied for Deprivation of Liberty Safeguards authorisations, which the local authority had granted. However, we found three we looked at had expired. This meant the provider was depriving people of their liberty illegally.

The records in the handover book showed that people had good access to physical healthcare; however, staff had not recorded this in people's care files. This meant it would be difficult to see people's healthcare history.

We saw good interaction between staff and people who used the service. It was clear from our observations that staff knew people well. Relatives told us staff were kind and they were happy with the care their loved one received. Staff maintained people's privacy and dignity. However, we found care records were kept in an unlocked cabinet in an unlocked office in the reception area of the home.

People's care records contained conflicting information. The new manager told us they were reviewing care plans as they had identified they were lacking in detail. We looked at the care plans of five people and found only one had been reviewed and updated. Staff told us there was no on-going assessment of peoples care. Staff had not consistently monitored people’s weights. We could not see referrals had been made to the GP or dietician where people had lost weight.

There were very few organised activities; the new manag

We carried out this inspection to follow up on concerns we found during our previous inspection on 7 April 2014. During that inspection we found that the provider did not have an effective system to regularly assess and monitor the quality of service that people receive.

At the time of this inspection we were told that 15 people were accommodated in the home.

During this inspection we spoke with the manager and looked at records relating to assessing and monitoring the quality of service provision.

We considered the evidence collected under this outcome and addressed the following question, is the service well-led?

Below is a summary of what we found. Please read the full report for the evidence supporting our summary.

Is the service well-led?

Since the last inspection visit a new manager had been appointed and was in the process of implementing new systems to monitor the quality of the service and identify risk. This would help to ensure that people received a safe and effective service.

You can see our judgements on the front page of this report.

Our inspection team was made up of an inspector, who addressed our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We saw that people were treated with respect and dignity.

The environment was clean, tidy and hygienically clean.

For the outcome areas we looked at during this inspection visit we saw that staff had received appropriate training.

We saw that the chef undertook temperature testing of food prior to it being served to people to ensure it was served at a safe temperature. However we saw that there were some gaps and inaccuracies in the recording of the temperature testing.

Is the service effective?

People living at Marple Lodge Care Home had a care file that included assessments of needs and a plan of care to meet their individual needs. However it was of concern that one person’s file could not be located during the course of this inspection visit.

The home was clean, tidy, free from offense odours and was nicely decorated and furnished.

Is the service caring?

The atmosphere in the home felt relaxed, pleasant and friendly. From our observations we saw that care staff had a good understanding of people’s individual needs and preferences. People were seen to be freely moving around the home and staff were kind and sensitive in their approach to people. We saw that staff responded promptly to peoples requests or need for assistance.

We observed that people looked well cared for and were appropriately dressed.

Some of the comments we received from people living at the home were: “The staff are lovely, I can’t fault them one bit” and “they (the staff) are marvellous.”

Is the service responsive?

We saw that where appropriate the service had accessed advice and care from other health care professionals. For example we saw evidence of visits from the GP, the district nurse, the chiropodist and we saw that people attended hospital appointments. This meant that people using the service received co-ordinated care and support.

We saw that there was a complaint procedure and we were told that each person living at the home had been given a copy of in the service user guide. We were told that the home had not received any formal complaints but had an open door policy and were quick to respond to any issues or concerns people had. We were told that people living at the home and /or their visitors were actively encouraged to raise any issues they had.

Is the service well-led?

The provider told us that interviews were due to take place the week following our inspection visit for the position of manager for the service.

Some documents and files could not be located during the course of our inspection and the management of the home was disorganised and chaotic.

There was not an effective quality assurance system in place to assess and monitor the quality of the service provided. This meant that poor practices may not be quickly identified and people could be placed at risk..

During this inspection we spoke with the deputy manager, a senior carer, two care workers, the cook, five people living at the home and one visiting relative. People spoken with were all positive about the service they received.

All staff spoken with were positive about the standard of care provided at the home.

We found that each person had individual care records that identified their care needs.

We looked around the home and saw that the layout of the premises was safe and suitable for carrying out the regulated activity. The premises were maintained to high standard as was the décor and furnishings of the home.

People spoken with told us they were happy with the standard of food and drinks and snacks were available on request. However some improvements were needed in the care planning process and assessment of people who may be at risk of not receiving adequate nutrition and hydration. Some shortfalls were identified due to the lack of training for staff who were involved in food preparation.

We saw that staff were available in sufficient numbers to meet people’s needs.

We found that care was provided in an environment that was clean, modern and bright. People who used the service were accommodated in single or shared bedrooms.

We sampled six care files and found them to be well maintained. Each file contained detailed assessments of personal care needs and risk assessments.

We observed that people looked comfortable and well cared for. When we spoke with three people who used the service comments included: "I have no complaints at all", "The staff here look after me very well" and "I am very happy here". We also spoke with two visitors during the inspection and they raised no issues at all about any aspect of the care provided.

We reviewed how medicines were managed in the home. We saw appropriate arrangements were in place in relation to obtaining, storage and disposal of medicines.

We found that Marple Lodge had appropriate systems in place to ensure that staff were recruited safely and effectively. We looked at a sample of six staff recruitment files and saw that they contained the required information, which included, two written references and proof of identity, all obtained before people began working at the home.

We found that complaints were managed appropriately. When we spoke with people who used the service, we were told: "I have no complaints at all, the staff here are very good", "I have nothing to complain about" and "I have never had any reason to complain, I am very happy".

People who use the services at Marple Lodge Care Home all had a diagnosis of Dementia or mental health problems. This meant it was difficult for people to reliably give their verbal opinions on the service they received. We did speak to people living at Marple Lodge Care Home and we also looked at people’s records, how people interacted with the staff, general observations throughout the visit and discussion with staff and visiting relatives.

People appeared relaxed and content. The people we spoke to said they liked the food and that they were “ok”. They told us they had everything they needed and had no complaints.

We spoke to several visiting relatives to the home, who were all positive about the care received by their relative. Some comments from relatives included:

“People’s privacy and dignity is respected.”

“The staff encourage people to have choices.”

“I think care needs are met.”

“The quality of care is excellent and is improving.”

“When I visit ‘X’ always looks clean and tidy and he seems happy here.”

“There is a very friendly atmosphere here and the new conservatories are really lovely.”

“They have activities every day for people.”

” I feel ‘x’ is totally safe, I don’t have any worries at all.”

As part of this review process we contacted Stockport Commissioners and Stockport Local Involvement Networks (LINks). LINKs are groups of individual members of the public and local voluntary/community groups who work together to improve health and social care services. They gather the views of local people and use them to influence how health and social care is commissioned and delivered. No concerns were raised.