The inspection took place on 04 and 05 December 2018, the first day of the inspection was unannounced.

Miramar 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. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Miramar Care Home accommodates 122 older people and people living with dementia in one building. The service has 10 single bedrooms with en suite bathrooms and 69 apartments for one or two people. There were 58 people using the service at the time of our inspection. Three people did not receive any care or support. Two people moved in to the service on the second day of the inspection. Eight people lived in the Cypress suite which was a dementia unit within the service. Most people using the service were able to tell staff how they preferred their care provided.

At the last inspection on 05 June 2018 we rated the service Requires Improvement overall. We found continued breaches of Regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a new breach of Regulation 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The registered provider submitted an action plan dated 22 August 2018 to detail how they planned to meet the breaches of regulations.

We undertook an unannounced focused inspection of Miramar Care Home on 04 December 2018. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection on 05 June 2018 had been made and because information of concern had been received. The team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. This is because the service was not meeting some legal requirements. During our focused inspection we found that the provider had not met all of their actions detailed in their action plan.

No risks or concerns were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

A registered manager was leading the service and was supported by a management team and the provider. A registered manager is a person who has registered with CQC to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider did not follow safe recruitment practices. Gaps in employment histories had not been explored to check staff suitability for their role.

At the last inspection registered persons had failed to deploy sufficient numbers of staff to meet people’s needs. Since our last inspection the registered manager had reviewed people’s care needs and the layout of the building. To support more efficient staff deployment the building had been divided into individual units and people were being given the opportunity to move to new apartments in these units. Some people had taken up this offer and had moved and further moves were planned. Despite these changes, staff deployment remained a concern. People had mixed views on the response times to call bells. Meal times and first thing in the morning when people wanted to get up and ready were key times of the day where staff were busy providing care and support and responding to people’s needs. Call bell records evidenced some people often had long delays to receiving an answer to their call. This is an area for improvement.

At the last inspection the registere

This inspection was carried out on 5 and 6 June 2018 and was unannounced.

Miramar 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. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Miramar Care Home accommodates 122 older people and people living with dementia in one building. The service has 10 single bedrooms with en suite bathrooms and 69 apartments for one or two people. There were 60 people using the service at the time of our inspection. Most people using the service were able to tell staff how they preferred their care provided.

A registered manager was leading the service and was supported by a management team and the provider. The registered manager had been employed after our last inspection. A registered manager is a person who has registered with CQC to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 2 May 2017, we asked the provider to take action to make improvements to the way the service was managed, including complaints management, acting on people’s views, the deployment of staff to meet people’s needs and how they supported staff to fulfil their role. We also required improvements were made to the way in which risk associated with people’s care and emergency situations were assessed and mitigated.

At this inspection we looked to see if the action the provider had taken had been effective. The company which owned Miramar Care Home had been sold to Avery Healthcare approximately four weeks before our inspection. They had not changed anything at the service in this time and had plans in place to make gradual changes with the registered manager and staff to improve the service.

The registered manager had made improvements to the service. However, further improvements were needed address the continued breaches of three regulations, including how risks to people were managed, how staff were deployed at busy times of the day and how people’s views were used to improve the service. We found two new breaches of regulation.

Action had not been taken since our last inspection to deploy more staff at busy times of the day and people continued to wait for long periods of time for the support they needed. People and staff continued to raise their concerns about this with the registered manager but action had not been taken to address them.

Staff, including nurses, had met with a manager since our last inspection to discuss their role, any problems they were experiencing or their personal development. However, these meetings were not held regularly. Nurses had not received clinical supervision to support them to maintain and develop their skills. Staff, including nurses, had been supported to complete the training they needed to fulfil their roles since our last inspection. Some staff held recognised qualifications in care.

People, their relatives and staff had been asked for their views of the service. These had not been reviewed and used to improve the service. For example, 12% of people had said they did not feel safe at the service but action had not been taken to address this. Checks and audits of the service had been completed but these had not identified the shortfalls we found during our inspection.

Assessments of people’s needs and risks had been completed and risks to some people, such as weight loss had been identified. Plans had been put in place to mitigate the risks but records of the action taken had not been maintained. Checks could not, therefore, be completed by staff and visiting health care professionals to make sure t

Signature at the Miramar provides accommodation and personal and nursing care for up to 122 older people and people living with dementia. The service is a large purpose built property. Accommodation is arranged over three floors. Two lifts are available to assist people to get to the upper floors. The service has 10 single bedrooms with ensuite bathrooms and 69 apartments for one or two people. There were 72 people living at the service at the time of our inspection, the registered manager was not able to tell us how many people were receiving a personal care service.

A registered manager was working at the service and was supported by a management team and the providers. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We inspected the service sooner than we had planned because we had received a number of concerns about people’s care from relatives and staff. One person’s relative told us, “The service was sold to us as ‘they do everything’, but it hasn’t turned out that way”. People had very different experiences of care at the service. People who required frequent support or had complex needs told us they did not receive their care when they needed it and often had to wait for assistance when they rang for help. Other people who required very little support found the service met all their needs. One person told us, “I have no concerns at all, I am well looked after”.

The registered manager did not have the required oversight of the service. They had not supported staff to work as a team and staff were demotivated and did not feel supported. Concerns staff had raised with the management team had not been listened to and acted on. Staff, including nurses, had not met with a manager to discuss their role, any problems they were experiencing or their personal development. Staff shared a vision of a good quality care but had not been supported to achieve this all of the time. Checks and audits of the service had been completed but these had not identified all the shortfalls we found during our inspection.

A system was in place to consider people’s needs when deciding how many staff were required to support them at different times of the day. This was not effective and there were not enough staff available to provide the care people needed when they needed it. Some people had to wait f to receive support to meet their basic needs, such as going to the toilet. People and staff had raised their concerns about staffing with the registered manager but action had not been taken to address them.

At our last inspection we recommended that the provider contact the local fire and rescue service for advice about keeping people safe in an emergency. This action had not been taken and detailed plans and equipment were not in place to assist people to evacuate in an emergency. We informed the local fire and rescue service of our concerns and they arranged to complete a fire safety audit of the service.

Assessments of people’s needs and risks had been completed. Risks to some people, such as weight loss which was not planned had not been identified. Action had not been taken to mitigate the risks and people continued to be at risk. Care had been planned with people to meet their needs. However, detailed information was not available to staff about people’s preferences and people told us that agency staff did not always provide their care in the way they preferred.

Staff had not completed all the training they needed to fulfil their roles including the nursing skills required to meet people’s needs. Some staff held recognised qualifications in care.

The Care Quality Commission

This inspection was carried out on 18 and 19 February 2016 and was unannounced.

Signature at the Miramar provides accommodation and personal and nursing care for up to 122 older people and people living with dementia. The service is a large purpose built property. Accommodation is arranged over three floors. Two lifts are available to assist people to get to the upper floors. The service has 10 single bedrooms with ensuite bathrooms and 69 suites and apartments for one or two people. There were 70 people living at the service at the time of our inspection, five people were not receiving a care service.

A general manager was leading the service. The registered manager had recently left the service and had applied to cancel their registration. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the care and has the legal responsibility for meeting the requirements of the law. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were treated with dignity and respect at all times. Staff told us they treated people as they would like their family to be treated. People and their relatives told us that the service felt like a family and staff were kind and caring.

The general manager provided leadership to the staff and had oversight of the service. Staff were motivated and felt supported by the management team. The general manager and staff shared a clear vision of the aims of the service. Staff told us the general manager and members of the management team were approachable.

There were enough staff, who knew people well, to meet their needs at all times. The needs of the people had been considered when deciding how many staff were required on each shift. Staff were clear about their roles and responsibilities and worked as a team to meet people’s needs.

The provider’s recruitment procedures were not followed consistently. The checks they required, to make sure staff were honest, trustworthy and reliable had not been fully completed for all staff. Disclosure and Barring Service (DBS) criminal records checks had been completed. The DBS helps employers make safer recruitment decisions and helps prevent unsuitable people from working with people who use care and support services.

Staff were supported to provide good quality care and support. Staff had completed the training they needed to provide safe and effective care to people and systems were in place to continually develop staffs skills and knowledge. Some staff held recognised qualifications in care. The providers process of regular meetings between staff and a manager to discuss their role and practice had not been followed for all staff. However, staff told us they felt supported and were confident to raise any concerns they had.

Staff knew the signs of possible abuse and were confident to raise concerns they had with the manager or the local authority safeguarding team. When concerns were raised action had been taken promptly to keep people as safe as possible. Robust plans were not in place to in place to keep people safe in an emergency, including plans and equipment to evacuate people from the building. Following the inspection plans were put in place to obtain advice from the local fire and rescue service.

Staff provided the care people required in the way they preferred. People’s needs assessed and regularly reviewed to identify the care they required and any changes. Care and treatment was planned with people and reviewed to make sure people got their care in the way they preferred and support them to be as independent as possible.

People received the medicines they needed to keep them safe and well. Action was taken to identify changes in people’s health, including regular health checks. People were supported by staff to rec

Our inspection of 21 May and 13 June 2013 found that improvements were needed to ensure that people were protected from the risk of receiving unsafe or inappropriate care. At this time we issued three warning notices to the provider.

In response to the notices the provider stopped taking admissions and developed an action plan demonstrating how they planned to become compliant with the regulations.

During this inspection we found that improvements had been made and the provider was compliant.

At the time of our inspection there were 66 people receiving a service from Signature at the Miramar. We spoke with people using the service and their representatives. We also spoke with the provider, the manager and staff

People told us that the provider had listened to their concerns about the service and taken action to improve the service. Staff told us they had been supported by the provider to improved service people received. We found evidence to confirm this.

One person told us, “Overall we are quite pleased with the staff, they are very good”. Another person said, “I think the service is remarkable”.

We found that people’s privacy had improved and there were sufficient staff to meet their needs consistent and in a timely way.

People’s care was planned and delivered safely to meet their needs.

People were protected from the risks of malnutrition and dehydration.

People's personal records were accurately maintained and supported staff to meet their needs.

We spoke with 5 people out of 65 at the home at the time of the inspection. We also 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.

People told us that they were happy with the care they received at the home, and one person said “I get to make my own decisions”. Other people said “it is very nice here”, and “staff treat me very well”. One person said that he got on well with all the staff at the home, and would not consider leaving, as he had been there for over six years.

We spoke to people who told us that the staff “really look after us”, and that the home was “immaculate”, and they would not change a thing. Another person told us that staff provide everything he needs, and that the food was lovely and plentiful.

We spoke to four residents and two relatives of residents, who told us that they thought the staff were “excellent”, and helped them to feel independent. The relatives said they were made to feel at home and relaxed at the care home. The residents said the choice and presentation of food was “terrific”. Thank you cards left in the reception area by previous residents and relatives included comments such as “kindness was greatly appreciated, made friends and family very welcome, and appreciated everything that was done”.

At the time of our inspection there were 68 people receiving a service from Signature at the Miramar. We spoke with people using the service and their representatives. We also spoke to the manager and staff providing the service

People were complimentary about the majority of the staff, one person told us, “the staff are very cheerful and very kind”. People told us that there were not enough staff available to meet their needs. We found that people’s needs were not always met in a consistent or timely way. We judged that this had a major impact on people.

People told us they lacked privacy on occasions. We found the service was aware of this but had not taken action. We judged this had a moderate impact on people.

The provider had not taken action to ensure each person’s care was safe and met their needs. Care was not consistently planned and delivered in response to people’s changing needs. We judged this had a major impact on people.

People had choices about what they ate, where and when. They told us the food was good and they enjoyed it. However, we found that the service had not ensured that people were protected from the risks of malnutrition and dehydration. We judged this had a noderate impact on people

People’s personal records were accurately maintained and people were at risk of receiving care that did not meet their needs. We judged that this had a major impact on them

We found that the provider had not notified us of significant events.