We inspected Queen Mary's and Mulberry House Nursing Home on 22 and 23 October 2018. The first day of the inspection was unannounced.

Queen Mary's and Mulberry House Nursing Home 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. Queen Mary's and Mulberry House Nursing Home provides accommodation and nursing care for up to 72 older people and younger people, some of who had physical disabilities. At the time of the inspection there were 59 people living at the home. Queen Mary's and Mulberry House Nursing Home is run as one and the home is divided into two units. Queen Mary's provides nursing care for people living with healthcare needs such as stroke, heart disease diabetes and dementia. Mulberry House provides nursing care and support for people living with an acquired brain injury. This can be because of an accident or following a health-related condition, such as a stroke or Parkinson’s disease. There were also some people, with a learning disability, living at the home. Most of whom also had an additional nursing need.

There were some people at the home living with a learning disability. CQC have developed guidance for homes who look after people with a learning disability. This is called Registering the Right Support. We have written to the provider to ask how they will develop the service to ensure it embraces the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. This is so people with learning disabilities and autism using the service, can live as ordinary a life as any citizen.

There was a registered manager at the service. 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 had previously carried out an inspection in April 2016 where we rated the service as good, although we asked the provider to make improvements in relation to the recording and management of wounds. At this inspection we found improvements had been made in relation to wound management and the evidence continued to support the rating of Good. We found improvements were needed to some aspects of record keeping. However, there was no evidence or information from our inspection, and ongoing monitoring, that demonstrated serious risks or concerns.

This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Improvements were needed to ensure people’s records always reflected the care and support they needed and received. Staff knew people well and had a good understanding of them as individuals and the care and support they needed. People received care that was person-centred and met their individual needs and choices. Activities were developed to meet each person’s needs.

People were supported by staff who were kind and caring. They treated people with kindness, understanding and patience. People were supported to make decisions and choices about what they did each day and their dignity and privacy was respected.

People’s safety was maintained because staff had a good understanding of the risks associated with the people they looked after. Risk assessments were in place and provided guidance.

People’s medicines were ordered, stored administered and disposed of safely. They were protected from the risks of harm, abuse or discrimination because staff had a good understanding of safeguarding procedures and their own responsibilities. There were enough staff working to provide the support pe

Queen Mary's and Mulberry House Nursing Home is divided into two discrete units. Queen Mary's provides nursing care for up to 48 people and Mulberry House provides nursing care and support for up to 24 people with an acquired brain injury. On the days of the inspection, there were 47 people living at Queen Mary’s and 12 people living at Mulberry House.

Queen Mary’s provides nursing support for people living with varying stages of dementia along with healthcare needs such as Parkinson’s, diabetes, strokes and heart disease. Mulberry House cares for people with an acquired brain injury, this included post trauma as well strokes. There was a multi-agency approach to care and support which included physiotherapists and occupational therapists working alongside the care team. The age range of people living at the home varied from 23 –100 years old.

Accommodation was provided over two floors with lifts that proved level access to all parts of the home. Thought and consideration had been given to the environment of the home, making it as comfortable and user friendly as possible. People spoke well of the home and visiting relatives confirmed they felt confident leaving their loved ones in the care of Queen Mary's and Mulberry House Nursing Home.

A manager was in post and was in the process of registering with CQC. 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 and associated Regulations about how the service is run.

At the last inspection on 28 January and 02 February 2015 we asked the provider to make improvements to the safety and welfare of people, infection control procedures treating people with dignity and respect, ensuring equipment was properly maintained and the monitoring and assessing the quality of the care and support provided. The provider sent us an action plan stating they would be addressed by December 2015. We found our concerns had been addressed and the breaches in regulation met.

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made.

Care plans reflected people’s assessed level of care needs and care delivery was person specific and in line with the care plans. The delivery of care was based on people’s preferences.

The care planning system had been reviewed and records for each person were specific to their needs, with guidance for staff to ensure people received the support and care they needed and wanted. We saw care plans that contained information about people’s skin integrity alongside the risk assessment to identify people’s individual risk to pressure ulcers. However we did find gaps in documentation that identified that some people’s skin had deteriorated to a wound without changes to the risk assessment or care plan. There was no indication of staff awareness of the development of the wound. This was discussed in full and as requested a full root core analysis was undertaken by the manager with timelines of the pressure wounds following the inspection.

Risk assessments included, falls, skin damage, behaviours that distress, nutritional risks including swallow problems and risk of choking and moving and handling. For example, cushions were in place for those that were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and epilepsy.

Nurses were involved in writing the care plans and all staff were expected to record the care and support provided and any changes in people’s needs. The manager said care staff were being supported to do this and additional training had been arranged. Food and fluid charts were completed and showed people were supported to have a nutritious diet.

Staff had a good understand

One inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. We spoke with five people who lived at the home, one relative and four members of staff, including the registered manager. We also spoke with a community nurse who was visiting the home.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found

Is the service safe?

People were treated with respect and dignity by the staff. People who used the service told us they felt safe. A relative told us, "It's a real comfort to know that mum is safe and well cared for."

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 compiled the staff rotas, they took people's care needs into account when they made decisions about the numbers, qualifications, skills and experience required. This helped ensure that people's needs were always safely met.

Policies and procedures were in place to make sure that unsafe practices were identified and people were protected.

The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and how to submit one. This meant that people were safeguarded as required.

Is the service effective?

People's health and care needs were assessed with them, and, as far as practicable, they were involved in developing and reviewing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

People and their relatives said that they had been involved in reviewing care plans and they reflected their current needs.

People's needs were taken into account with the accessible layout of the service, enabling people to move around freely and safely.

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

The home had systems in place to assess and manage risks and to provide safe and effective care. The staff were appropriately trained and training was refreshed and updated regularly. Staff could also take the opportunities provided to study for additional qualifications and to develop their understanding of caring for people with conditions such as dementia and mental health illnesses. We also found evidence of staff seeking advice, where appropriate, from the GP or social services.

Is the service caring?

People were supported by kind and attentive staff. We saw that all staff that had contact with the people who used the service showed patience and empathy. A person who used the service told us, "Everyone here is so kind and helpful – I'm very satisfied."

We spoke with relatives who said they were able to visit at any time and they were always made to feel very welcome. They told us “Whenever I visit there are always staff around and they are kind, friendly and provide good quality care.” We saw that the staff took time with people over lunch and when they were moving about within the home. We observed high levels of respect and people were treated sensitively with consideration and dignity.

People who used 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 had the opportunity to take part in a range of activities, reflecting their interests and preferences, both in and outside the service. A care worker told us "We spend time with people and get to know them individually, so we can find out what their interests are and how they like to spend their day.”

People’s needs were assessed before they moved into the home and detailed care plans and risk assessments were maintained and reviewed regularly. This ensured that the care and support provided reflected any identified changes in people’s individual care needs. We saw that the staff monitored weight, nutrition and hydration and handover sessions were helpful and informative.

We were told by the organisations director and deputy manager that the service had good systems in place to monitor its own standards of service delivery and to gain feedback from people who used the service, their relatives and other stakeholders. As well as satisfaction questionnaires, the deputy manager told us they operated an 'open door policy' so people who used the service and visitors to the home could discuss any issues they may have.

People told us they were asked for their feedback on the service and their feedback was heard and changes were made as a result. People and their relatives, who we spoke with, also knew how to make a complaint or raise any issue or concern that they might have. They were also confident that their concerns would be listened to and acted upon.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up and consistent way.

The service had 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. They also told us that they felt valued and supported by the management team and were happy and confident in their individual roles.

We spoke to eight people and three visitors during our inspection visit. We also used a number of different methods such as observation of care and reviewing of records to help us understand the experiences of people who used the service. People we were able to speak with who lived in the service told us they liked living at queen Mary's and Mulberry House. We were told "Lovely place to stay, sometimes I grumble but the staff are very good," "Caring and kind staff," and, "Staff look after us very well." We also spoke with relatives/visitors. One visitor told us "Great place, the staff are very kind and the home is always clean and comfortable."

People were enabled to express their views and were involved in making decisions about their care and treatment. We found that care and treatment was planned and delivered in a way that ensured people's safety and welfare. Medicines were prescribed and given to people appropriately and safely. There was enough specialised equipment to promote the independence and comfort of people who used the service. We saw documentation that the provider responded appropriately to any allegation of abuse. There were enough qualified, skilled and experienced staff to meet people’s needs. People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. We saw that complaints were taken seriously and there was an effective complaints system available.

People felt that they were asked for consent and had individual care and treatment discussed with them.

People spoken with including two relatives told us that the care and treatment provided met their needs.

Comments received included ‘’I am looked after very well’’ ‘’I have a shower every week but you can have one every day if you want’’.

All feedback from people living in the home relatives and staff was positive about the standard of cleanliness in the home. Telling us that it was always clean.

People using the service told us that there was always enough staff working in the home to meet their needs. All feedback about the staff was positive with people saying ‘’the staff are excellent’’ ‘’the staff are so kind’’.

People told us that they were asked about the home and what they thought about the care and service.

Four people living in the home were spoken to in depth and shared their views on the service provided. Four visitors were also happy to comment on the home and how it was meeting their relative or friend’s needs.

People spoken with were able to talk about the choices they are given and how these are respected. This included those around food ‘I can have what I want for breakfast’ and about care and lifestyle ‘I like to do my own thing and make my own bed’.

One person spoken with said that he had consented to the care and treatments that he receives and is happy with the care and support that is provided by the home.

Everyone spoken with complimented the care provided within the service with one regular visitor saying ‘everything is perfect’. People who use the service commented on the care saying ‘I am well looked after’ ‘I have help with showering and bathing as often as I want’ ‘I like living here and feel safe’.

People living in the home are mostly satisfied with the food provided and comments made included ‘the food is ok and I can have anything I want for breakfast’ ‘I do not eat a great deal but I am given special drinks’. Another person using the service said the food was ‘alright’ and advised that staff would always get her something else if she did not want what was on the menu’.

One person spoke about how she has regular contact with her social worker and that the manager of the home works with her.

One person commented on how well the laundry was dealt with and a relative specifically commented on how clean the home was ’my husband has a lovely room and the home is very clean’.

Everyone spoken with expressed a satisfaction with their own rooms and the way it is decorated and the facilities.

People who use the service said that there are enough staff working in the home to support them. One person said that his ‘bell gets answered when rung’ and another said ‘staff are very nice and always around’

People spoken to expressed a satisfaction with the staff with comments including ‘I have found the staff honest and trustworthy’ ‘the staff are kind and they are friends as well’ ‘staff are lovely’.

People spoken with felt that if they had any concerns or complaints staff would respond to them quickly and that it would be dealt with. Most said that they would talk with the manager directly or with a trained nurse.

One person along with her representative explained how the appointed manager had responded positively to a concern causing distress. She fully investigated the issue and was able to put in place a good resolution.

We inspected Queen Mary's and Mulberry House Nursing Home on the 29 January and 02 February 2015. Queen Mary's and Mulberry House Nursing Home is divided into two discrete units. Queen Mary's provides nursing care for up to 48 people and Mulberry House provides nursing care and support for up to 24 people with an acquired brain injury. On the days of the inspection, there were 48 people living at Queen Mary’s and 14 people living at Mulberry House.

Queen Mary’s provides nursing support for people living with varying stages of dementia along with healthcare needs such as Parkinson’s, diabetes, strokes and heart disease. Mulberry House cares for people with an acquired brain injury, this included post trauma as well strokes. There was a multi-agency approach to care and support which included physiotherapists and occupational therapists working alongside the care team. The age range of people living at the home varied from 23 –100 years old.

Accommodation was provided over two floors with lifts that proved level access to all parts of the home. Thought and consideration had been given to the environment of the home, making it as comfortable and user friendly as possible. People spoke well of the home and visiting relatives confirmed they felt confident leaving their loved ones in the care of Queen Mary's and Mulberry House Nursing Home.

A manager was in post and was in the process of registering with CQC. The manager had just completed her probation period as 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 and associated Regulations about how the service is run.

At the last inspection in May 2014, we found they had met all the essential standards inspected.

People spoke positively of the home and commented they felt safe. However we found that people’s safety was being compromised in a number of areas. For example, not all people who lived with epilepsy had a care plan to manage their epilepsy and seizures. There were no triggers identified for staff to react to and manage safety. Specialised equipment for peoples’ very complex needs had not been checked or evidenced regular servicing to ensure it was working and safe. We also found that people were not fully protected from the risk of cross infection whilst receiving care.

Whilst people were able to make decisions about what they wanted to eat and drink and were supported to stay healthy, there was little evidence of health promotion initiatives around the home for people to see or even know about. Such as smoking cessation or mental health advice.

Quality assurance systems whilst in place had not identified the shortfalls found in care plans or in the maintenance of the specialised equipment used for people. Despite concerns with the provider’s quality assurance framework, people received care that met their needs in a personal and individual manner. However, we have identified the above as a breach of regulation 10.

People were cared for, or supported by, sufficient numbers of suitably qualified and experienced staff. Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.

Training schedules confirmed staff members had received training in safeguarding adults at risk. Staff knew how to identify if people were at risk of abuse or harm and knew what to do to ensure they were protected.

People’s medicines were stored safely and in line with legal regulations. People received their medicines on time and from a registered nurse.

Staff understood the principles of consent and respected people’s right to refuse consent. All staff had received training on the Mental Capacity Act 2005 (MCA) and mental capacity assessments were consistently recorded in line with legal requirements.

People had a care plan which outlined their needs and the support required to meet those needs. Care plans were personalised and included information on people’s individual likes, dislikes, daily routine and what was important to that person.

Accidents and incidents were recorded appropriately and steps taken by the service to minimise the risk of similar events happening in the future. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People were treated with respect and dignity by staff. They were spoken with and supported in a sensitive, respectful and caring manner.

People felt well looked after and supported. We observed friendly and genuine relationships had developed between people and staff. People were seen laughing and smiling with staff. Staff understood the importance of monitoring people’s health and well-being on a daily basis.

Staff received on-going training and support which enabled them to provide effective care. Staff spoke positively of the manager and demonstrated a commitment to providing good quality care.

There were opportunities for additional training specific to the needs of the service. This included care of the tracheostomy, speech and communication strategies and the management of acquired brain injuries. Staff had received regular supervision meetings with their manager, and formal personal development plans, such as annual appraisals, were in place.

There was a multi-agency approach to care delivery that was essential to meeting a range of complex needs. There was input from physiotherapists, psychologists and occupational therapists that ensured all aspects of care delivery were explored. Activities were meaningful to people and promoted their identity and self-worth. Staff regularly took people out to local shops, cafes and for outings. People’s lifestyle choices and diverse social and cultural needs were maintained and supported.

Feedback was regularly sought from people, relatives and healthcare professionals. The manager and staff continually strived to make improvements and deliver care that was personal to each person.

Staff told us about the home’s vision and values statement. The provider had mechanisms to assess the effectiveness of care plans. People received care which met their needs in a personal and individual manner.

We found a number of breaches including continuing breaches of the Health and Social Care Act 2008(Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.