We inspected Marriott House and Lodge on 9 October 2018 in light of information of concern that we had received in respect to people’s care. Marriott House and Lodge 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. Marriott House and Lodge is registered to provide care and accommodation for 119 older persons with nursing, residential care and physical care needs. Accommodation is provided in two separate buildings. Marriott House provides care and support for people with nursing needs over three floors and Marriott Lodge provides residential care for people over four floors. There is a passenger lift in both buildings to provide access to people who have mobility issues. On the day of our visit 50 people were living in Marriott House and 34 people were living in Marriott Lodge. We previously inspected Marriott House and Lodge on 19 and 20 October 2017 and found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found concern in relation to staffing levels, people’s dignity being respected and quality monitoring and the service received a rating of requires improvement overall. We asked the provider to take action to make improvements. The provider sent us an action plan stating how they intended to improve, and these actions have been completed and the provider was now meeting legal requirements. However, at this inspection, we found further areas of practice that needed improvement.

There was no 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. Day to day management of the service was carried out by an interim general manager, a senior deputy manager and a deputy manager. However, despite having management arrangements in place, the service had been without a registered manager for a significant period of time.

On the day of our Inspection there were sufficient staff to support people. However, the provider relied heavily on agency staff and this had impacted on people’s experience of the care they received.

People felt well looked after and supported. We observed friendly relationships had developed between people and staff. People were treated with dignity and respect, and they were encouraged to be as independent as possible.

The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

Risks associated with people’s care, the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People chose how to spend their day and they took part in activities. They enjoyed the activities, which included, arts and crafts and visits from external entertainers. There were representatives from local churches, so that people could observe their faith. People were also encouraged to stay in touch with their families and receive visitors.

People were cared for in a clean and hygienic environment and appropriate procedures for infection control were in place. Healthcare was accessible for people and appointments were made for regular check-ups as needed.

Care plans described people’s preferences and needs, including their communication needs. People’s end of life care was discussed and planned and their wishes had been

Marriott House and Lodge is registered to provide care and accommodation for 119 older persons with nursing, residential care and physical care needs. Accommodation is provided in two separate buildings. Marriott House provides care and support for people with nursing needs over three floors and Marriott Lodge provides residential care for people over four floors. There is a passenger lift in both buildings to provide access to people who have mobility issues. On the first day of our visit 54 people were living in Marriott House and 29 people were living in Marriott Lodge.

The home did not have a registered manager, the previous registered manager had left on 12 May 2017. 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.

A manager was in post but they had not applied to become registered with CQC. They told us that they were leaving and the second day of our visit coincided with their last day in post. The provider’s regional director was present during the inspection and told us that a new manager had been appointed and was due to start the week following the inspection.

At the last inspection on 4 and 5 August 2015 we had no concerns and the service was rated ‘Good’ overall. At this inspection we found three breaches of the regulations and other areas of practice that needed to improve.

There were not always enough staff to care for people safely. People and their relatives expressed concerns that people had to wait for their care needs to be met. One person said, “At times I have to wait for staff and when they do come they always appear rushed.” Another person commented, “Sometimes you wait over half an hour.” Call bell records confirmed that people regularly waited for longer than they should reasonably expect for staff to respond. This was identified as a breach of regulations. The provider took immediate action to increase staffing levels and improvements were noted on the second day of the inspection.

Most people and their relatives spoke highly of the staff and the care they received. One person said, “They are a very nice group of girls, I call them my grand-daughters.” However people’s dignity was not always protected because staff were not responding to call bells in a timely way. Some people told us that staff were not always kind and caring. One person said, “There are some good ones (staff), and some are not so good. They do what has to be done but don’t look beyond that.” A relative described how they had heard a staff member speaking 'sharply' to their relative. People and their relatives told us that most of the staff were kind and caring in their approach however not all interactions between staff and people were consistently positive. This was identified as a breach of the regulations.

The provider had a number of management systems and processes including audits, to monitor quality at the home. However, these had not always been effective in identifying shortfalls in the quality of the service. There was a lack of management oversight in some areas of practice which meant that the manager could not always be assured that risks to people were being effectively managed. This was identified as a breach of the regulations.

People were receiving their medicines safely but some PRN (as required) medicines were not always documented clearly. This put people at risk of receiving inappropriate doses of their medicines and was identified as an area of practice that needed to improve.

Risks to people were identified and care plans were regularly updated to guide staff in how to provide care safely. However, staff were not always following the care plans consistently. This meant that people were at risk of receiving

Marriott House and Lodge is a privately owned care home for older people needing nursing care and accommodation. It is registered to accommodate up to 119 people. We were informed that, at the time of our visit, 52 people were accommodated at Marriott House and 34 people were accommodated at Marriott Lodge.

This inspection was carried out by one inspector. We gathered evidence that helped answer 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 using the service, their relatives, 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?

People were treated with respect and dignity by the staff.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. On the day of our inspection we were told no applications had been made under DoLS as it had not been necessary. The manager confirmed they understood when an application should be made to deprive someone of their liberty and how to submit one.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve

The registered manager set the staff rotas. They took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people’s needs were always met.

We observed medication records had not always been completed to confirm medication had been given. This meant that people may not have been given medication as prescribed. We also observed, where medication had been prescribed on an ‘as required’ basis, the reason why medication had been given and whether it had been effective had not been routinely recorded.

A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service effective?

People’s health and care needs were assessed with them, and they were involved in writing their plans of care.

Specialist dietary, mobility and equipment needs had been identified in care plans where required. People said that they had been involved in writing them and they reflected their current needs.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, “They look after us well”. A relative said, “I would not like to put my family member anywhere else”.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly.

People had meetings with heads of department to discuss their views and opinions of the service provided. We saw minutes of meetings which demonstrated that positive responses had been made to suggestions put forward to improve the service.

Is the service well-led?

The service has a quality assurance system, records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

On this occasion we concentrated our inspection on the care and services provided to people who lived at that part of the location known as Marriott House. People requiring nursing care have been accommodated here.

We spoke with three people who lived at Marriott House. We also spoke with some relatives who were visiting. Every one we spoke with told us they received the care and support they needed. They confirmed that their needs had been discussed with them and assessed prior to admission. They also confirmed that care plans had been discussed with them. Everyone we spoke with confirmed their satisfaction with the care provided and the hygiene standards maintained within the home.

One person told us, “Everything is absolutely A1!” Another person said, “Generally speaking, everything is excellent.” A relative informed us, “The staff are lovely. They are very competent; they know what they are doing.”

Staff on duty we spoke with were very knowledgeable about the needs and preferences of individual people. They knew what was expected of them to ensure identified needs had been met.

Overall the atmosphere with Marriott House was warm and homely. We observed care staff and other staff engaging with people. They conducted themselves in a friendly but professional manner, taking time to listen carefully to people to ensure they understood what was needed of them.

On this occasion we concentrated our inspection on the care and services provided to people who lived at that part of the location known as Marriott Lodge.

The registered manager of Marriott House and Lodge had delegated some duties and responsibilities for Marriott Lodge. This senior member of staff was called the care manager.

We talked to three people who lived at Marriott Lodge. They told us they received the care and support they needed. They confirmed that they have given their consent to this and have had their care plans discussed with them. One person told us, “We are getting the care that we agreed to.”

Everyone we spoke with confirmed their satisfaction with the service provided. One person told us, "The girls (care staff) are very nice!" They also told us they felt safe.

We asked if they believed there were enough staff on duty to deliver the care they needed. One person told us, “I wouldn't know. I just call and they come to help me.” Another person commented that the staff are very busy, especially at mealtimes.

People we spoke with could not recall if they had been given a written complaint procedure. One person told us, “I have had no complaints. I would not know what to do.” Another person told us they would speak to the care manager. They also said they found the care manager was approachable and would listen to their concerns.

We talked to four people who live at Marriott House and Lodge. They told us they receive the care and support they need. They were unable to confirm that they have given consent to this or have had their care plans discussed with them. Everyone we spoke with confirmed their satisfaction with the service provided. One person told us, “It is all very good. I can’t really find any faults!”

We also spoke to two members of staff who were on duty. They told us about the level care they provide to people at Marriott House and Lodge. They also told us about the support and training they have received to enable them to provide good quality care.

We spoke to the manager about the systems that were in place to assess and review the needs of each person. We also spoke to the manager about how the quality of service provision is assessed and monitored.

Marriott House and Lodge is registered to provide care and accommodation for 119 older persons with nursing, residential care and physical care needs. Accommodation is provided in two separate buildings. Marriott House provides care and support for people with nursing needs over three floors and Marriott Lodge provides residential care for people over four floors. There is a passenger lift in both buildings to provide access to people who have mobility issues. On the day of our visit 50 people were living in Marriott House and 36 people were living in Marriott Lodge.

At our last inspection to Marriott House and Lodge in May 2014 the registered provider was found to be in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 as there were concerns related to the safe management of medicines. The provider sent us an action plan stating they would be compliant with this regulation by 5 June 2014. At this visit carried out on 4 and 11 August 2015 we found that improvements had been made in this area.

The service had a registered manager in place. 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 and associated Regulations about how the service is run.

People told us they felt safe. Relatives told us they had no concerns about the safety of people. There were policies and procedures regarding the safeguarding of adults and staff knew what action to take if they thought anyone was at risk of harm.

Care records contained risk assessments to protect people from risks and help to keep them safe. These gave information for staff on the identified risk and guidance on reduction measures. There were also risk assessments for the building and contingency plans were in place to help keep people safe in the event of an unforeseen emergency such as fire or flood.

Thorough recruitment processes were in place for newly appointed staff to check they were suitable to work with people. Staffing numbers were maintained at a level to meet people’s needs safely. People and relatives told us there were enough staff on duty and staff and records also confirmed this.

People were supported to take their medicines as prescribed by their GP. Records showed that medicines were obtained, stored, administered and disposed of safely

Staff were supported to develop their skills through regular training. The provider supported staff to obtain recognised qualifications such as National Vocational Qualifications NVQ or Care Diplomas. Staff told us the training provided was good and they were provided with the training they needed to support people effectively.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Currently one person was subject to DoLS and we found the registered manager understood when an application should be made and how to submit one. We found the provider to be meeting the requirements of DoLS. There were no restrictions imposed on people and they were able to make individual decisions for themselves. The registered manager and staff were guided by the principles of the Mental Capacity Act 2005 (MCA) regarding best interests decisions should anyone be deemed to lack capacity.

The provider supported people to maintain family links and visitors were welcome at any time. We observed activities taking place for people. There was a comprehensive activities programme in operation throughout the day. The provider employed a team of staff who co-ordinated and provided a range of different activities. People and relatives said the activities available were first class.

People were satisfied with the food and said there was always enough to eat. People were given a choice at meal times. People were able to have drinks and snacks throughout the day and night. Meals were balanced and nutritious and people were encouraged to make healthy choices.

Staff supported people to ensure their healthcare needs were met. People were registered with a GP of their choice and the registered manager and staff arranged regular health checks with GPs, specialist healthcare professionals, dentists and opticians. Appropriate records were kept of any appointments with healthcare professionals.

People told us the staff were kind and caring. Relatives had no concerns and said they were happy with the care and support their relatives received. Staff respected people’s privacy and dignity and used their preferred form of address when they spoke to them. Observations showed that staff had a kind and caring attitude.

People told us the registered manager and staff were approachable. Relatives said they could speak with the registered manager or staff at any time. The registered manager operated an open door policy and welcomed feedback on any aspect of the service. Regular meetings were booked to take place with staff, people and relatives.

The provider had a policy and procedure for quality assurance. Weekly and monthly checks were carried out to help to monitor the quality of the service provided. The provider also had their own internal quality regulation team who conducted full audits of the service. If any shortfalls were identified an action plan was put in place to monitor and check that the necessary improvements were taking place.