This inspection took place on 12 and 13 December 2018 and was unannounced.

We last inspected the service on 21 November 2017 and was rated ‘Good’ overall with the key question of responsive rated as ‘Requires Improvement’. This was because we found that further improvements needed to be implemented in the provision of meaningful activities, staff understanding of person centred care and the timely completion of daily records in response to people’s needs.

At this inspection we found that the service had not made the required improvements in areas such as the provision of meaningful activities and the timely completion of daily records in response to people’s needs. We also found that the provider implemented management and staffing structure within the home may affect the safe and effective management of the home.

This means that the service is no longer rated ‘Good’ and has been rated as ‘Requires Improvement’.

Murrayfield Care 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.

Murrayfield Care Home accommodates up to 74 people. Within the building there were three floors, each of which had separate adapted facilities. Lifts were available within the home giving people access to all areas of the home. One of the units specialises in providing nursing care to people and the two other floors specialised in providing care and support to people living with dementia and physical health needs. At the time of this inspection there were 72 people living at the home.

A registered manager was 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.

Activities provision within the home did not always stimulate or engage people. Where scheduled activities were organised and facilitated by designated activities co-ordinators, people were seen to enjoy these. However, very little meaningful activity was initiated and delivered by care staff in the absence of activity co-ordinators.

Monitoring charts and records were not consistently and comprehensively completed by care staff to ensure people received care and support that was responsive to their needs.

End of life preferences and wishes were not always clearly documented within people's care plans.

Quality assurance processes in place allowed the registered manager and the provider to oversee the quality of care provision, identify issues, learn and implement improvements where required. However, where actions were identified, which were similar to those identified as part of this inspection, these had not been actioned effectively and improvements had not been made.

We found that the management and staffing structure implemented by the provider did not always support the effective management and running of the home.

Staffing levels were determined based on individual people’s levels of need. We saw that there were sufficient number of staff available around the home at the time of the inspection.

People and their relatives told us that they felt safe living at Murrayfield Care Home. All staff demonstrated a good understanding of safeguarding people from abuse and the actions they would take to report their concerns.

People’s care plans contained detailed risk assessments people’s identified risks associated with their health and social care needs. Further information was also documented to guide staff on how to support people to be safe and free from harm.

Staff told us and records confirmed that they felt supported in their role and received regular supervisio

This inspection took place on 21 and 22 November 2017 and was unannounced. At the last inspection on 18 and 19 October 2016 we found the service was in breach of six regulations as stipulated by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found that people were not supported by care staff in a person centred way. Care was not delivered in a way which was appropriate, met people's needs and reflected their preferences. The provider did not ensure that appropriate activities were organised and provided to people, which encouraged autonomy, independence and involvement within the community. People were not supported by care staff with dignity and respect. Care staff did not put person centred care into practice or provide care that ensured people were treated with dignity and respect. Care staff did not interact with people unless they requested attention.

The provider was not protecting people and was not doing all that was reasonably practicable to mitigate identified risks associated with people's care and support needs. The provider failed to ensure that people were appropriately supported with their nutritional and hydration needs in order to maintain their health and well-being. The provider did not ensure that all areas of the home and equipment used by the service were clean, suitable for the purpose for which they were to be used and properly maintained.

Quality assurance audits that were being completed were not effective as they did not highlight concerns and issues around the home which had been identified on inspection. Where issues were identified there were no action plans in place on how these issues were to be addressed and resolved and there was also a lack of evidence that staff were supported to fulfil their roles and responsibilities through regular supervisions and appraisals.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve each of the key questions to at least good. During this inspection we found that the service had made appropriate improvements to the issues that we identified and were also able to evidence sustainability of improvements that had previously been made.

Murrayfield Care Home is a ‘care home’ providing nursing care. 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.

Murrayfield Care Home accommodates up to 74 people in one purpose built building. Within the building there were three floors, each of which had separate adapted facilities. One of the units specialises in providing nursing care to people and the two other floors specialised in providing care and support to people living with dementia and physical health needs. At the time of this inspection there were 73 people using the service.

A registered manager was 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.

The service had made significant improvements in the fabric and condition of the home. The home was clean and improvements had been made to food preparation areas and other specific areas around the home. However, we did note that sluice rooms had not been kept locked and secure where required.

The service had implemented a number of checks to ensure the appropriate completion of fluid intake charts and to ensure people were appropriately hydrated. However, the effectiveness of these checks were inconsistent across the home because charts had not always been checked appropriately.

Some care staff were abl

This inspection took place on 18 and 19 October 2016 and was unannounced. Murrayfield Care Home provides accommodation, nursing and personal care for a maximum of 74 people, some of whom are living with dementia. At the time of the inspection there were 67 people using the service.

There was a registered manager in post. However, the registered manager was not available on both days of the inspection and the inspection process was supported by the deputy manager and the provider’s area 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. However, one week after the inspection we learnt that the registered manager had left their position and that the home did not have a registered manager in place.

At our last inspection in September 2015, we found that some aspects of medicines management were not safe. The provider was also found to be in breach of Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to the lack of documentation to show how staff were supported effectively through supervisions and appraisals. There was also no documentation to show that the service had completed any quality assurance audits

Due to the serious nature of the breach of Regulation 12, relating to unsafe medicine management, we had taken enforcement action against the provider. We issued a warning notice to the provider detailing the issues we found and requiring them to become compliant within a specified timescale. An unannounced focused inspection took place in December 2015 to check that this significant breach of legal requirements had been addressed. During the focused inspection, it was found that all legal requirements for the safe management of medicines had been met.

During this inspection we found that, although the service had made some improvements in relation to previous issues that we had identified, a range of other serious concerns were found in relation to the care and support that people received.

Care staff did not understand what person centred care was or how to support people living with dementia even though specific dementia awareness training had been delivered recently within the home. Care plans did not always have a life history booklet completed about the person and significant details about the person were not always recorded in the care plan.

Scheduled activities did not always take place. Very little interaction, activity or stimulation was noted to be initiated by care staff on duty and people were seen to be taken to the lounge and positioned to watch television throughout the day. Care staff did not appear to be caring and responsive to people’s mental and emotional well-being.

Over both days of the inspection, we observed people experiencing a poor mealtime and dining experience, which did not promote well-being and independence. There were no menus available for people to know what their meal was going to be on the day. People who required assistance with their meals were seen to be left waiting for prolonged periods of time before they were supported. Care staff were noted to have poor awareness of what was on the menu and on occasions did not offer people any choice of what they would like to eat.

Risks associated with people’s care and support needs had been identified and these had been assessed, giving staff instructions and directions on how to safely manage those risks. However, where records were needed to be kept in relation to monitoring fluid intake, these had not been completed to ensure that this area was safely monitored and that people were protected from the identified risks. Care staff were also unable to tell us which people’s fluid int

Murrayfield Care Home provides accommodation, nursing and personal care for up to 74 older people some of whom are living with dementia. There are three floors with the second floor providing support for people with dementia.

At the time of this focused inspection there was a new manager in post who has not yet applied to be the 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.

At the last inspection of this service on 11 and 14 September 2015 we found that some aspects of medicines management were not safe and there was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Due to the serious nature of the breach we took enforcement action against the registered provider.

After this inspection, the provider wrote to us to say what they would do to meet the legal requirements for the breaches we found. The provider confirmed that they would complete daily and weekly medicine audits on each unit and as part of that process would also review Medication Administration Records (MAR) for each person using the service. The provider also stated that they would review staff medicine training and ensure that all nurses undertook a medicine competency assessment.

We undertook this unannounced focused inspection on 2 December 2015 to check that the most significant breach of legal requirements in relation to Regulation 12, concerning medicines, which had resulted in enforcement action, had been addressed. During this inspection we found that the legal requirements as per Regulation 12 had been met.

This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Murrayfield Care Home on our website at www.cqc.org.uk.

We will undertake another unannounced inspection to check on all other outstanding legal breaches identified for this service.

Our inspection of 30 August 2013 found that care plans did not provide information about choices or preferences relating to people's care needs. At this inspection one person's comments were typical when they said, "they ask me how I want things done and know what I like to eat." We observed that people were involved and consulted about decisions affecting their care.

Our inspection of 30 August 2013 found that care plans did not provide clear and detailed information about people's care and the risks associated with meeting their needs. At this inspection one person said, “I am well looked after here.” We looked at three care plans and found that they provided information about people's needs and how these should be met. For example, a pain assessment had been carried out and staff knew how to identify when a person needed pain relieving medication.

Our inspection of 30 August 2013 found that care plan audits had not been carried out. The provider wrote to us and told us that they would carry out monthly care plan audits. At this inspection staff told us that care plan audits had been carried out and where issues had been identified these had been addressed. We looked at care plan audits that had been carried out between October 2013 and February 2013 and found that these identified where information about people's preferences and choices had not been included in their care plans. The manager had checked to make sure that this had been addressed.

We spoke with five people who use the service they told us that staff asked them how they wanted to be cared for. One person's comments were typical when they said, "staff take their time to find out what you want." When we looked at people's care records their choices and their ability to make decisions about their care and treatment had not been clearly identified. We looked at seven people's care plans relating to people's rights, consent and capacity needs and found these contained contradictory or insufficient information about people's choices and their ability to consent to care.

The care plans that we looked at did not provide clear and detailed information for staff about how people's needs would be met. Care plans were not personalised as they did not provide information about meeting each individual's needs, rather they used the same phrases that were repeated in each person's care plan.

The manager informed us that she had only been at the home for the past two weeks and had not carried out any care plan audits. She told us that the last audits would have been carried out in June 2013 by the previous manager. We asked to see these, but the manager was unable to locate them. We looked at seven care plans and found that they did not always contain complete information about people's care and treatment and the risks associated with supporting their needs. Regular audits of the quality of care plans were not being carried out to ensure people's safety.

We spoke with people who used the service. One person said, "staff do explain what they are going to do and ask if it is ok." Staff took the time to make sure that they involved people in decisions about their care, for example, when assisting them to eat. People said that they received the care and support they needed. A typical comment was, "staff are kind and helpful." Staff were approachable and listened to what people had to say.

People told us that they liked their meals. A person said, “the food is nice.” We asked people about the variety of food and, a person told us, “I can choose something different if I don't like what is on the menu." People were provided with a choice of suitable and nutritious food and drink.

There were effective recruitment and selection processes in place. Staff told us that they had been through a detailed recruitment process that included completing an application form, interviews and references being taken up from their former employers. People's personal records including their care plans were accurate, and had been reviewed and updated at regular intervals. Care records gave an explanation of how people's needs were to be met. This meant that care records supported staff to provide safe and appropriate care to people who use the service.

The five people spoken with told us that staff involved them in decisions about care and treatment. They received the care and support they needed. One person’s comments were typical when they said, "Staff understand my needs." The four staff spoken with confirmed they were told about the needs of people.

People spoken with confirmed that they trusted staff and felt safe. A person said, “I am safe here.” People said to us that staff were available to help them. People told us and we observed that staff listened to them. Staff responded to any suggestions they made about the service.

People and their relatives told us that staff involved them in decisions about care and treatment. One person said, "Staff were respectful." People said that they received the care and support they needed. A person said, "They asked how I wanted things done." People spoken to told us that they liked the food. When asked about the food a person commented, “The food is nice.”

People spoken to confirmed that they trusted staff and felt safe. They could discuss their concerns with the staff. We walked round the home and found that it was well decorated. People had been consulted about how they wished for bedrooms to be decorated. We saw that staff understood peoples’ needs. They told us that staff knew how to support them. A person told us when asked about how staff treated them, "The staff are helpful."

This inspection took place on 11 and 14 September 2015 and was unannounced. At our last inspection on 17 and 18 November 2014 we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These breaches were in relation to medicines management, consent to care, nutrition, assessment and welfare, quality assurance and health and safety monitoring.

Murrayfield Care Home provides accommodation, nursing and personal care for up to 74 older people over three floors. The second floor supports people with dementia.

There was a new manager who was recently in post. This new manager had not yet applied to be the 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 and associated Regulations about how the service is run.

Following our inspection in November 2014 and as a result of concerns about the service, the local authority had developed an improvement plan for the organisation and regular meetings were being held to monitor the standard and safety of the service. The provider had a voluntary suspension on admissions to the home and therefore since our last inspection the service had not taken on any new admissions. At the time of our inspection there were 43 people using the service.

Our inspection in September 2015 found that the service had addressed some of the breaches identified at the inspection in November 2014 but there were areas that still required improvement.

Positive caring relationships had developed between people who used the service and staff and people were treated with kindness and compassion. Relatives of people who used the service told us that they were confident that people were safe in the home. Systems and processes were in place to help protect people from the risk of harm. These included careful staff recruitment and systems for protecting people against risks of abuse.

Identified risks associated with people’s care had been assessed and plans were in place to minimise the potential risks to people.

Our inspection in November 2014 found that some aspects of medicines management were not safe. During our inspection in September 2015 we found that whilst the home had made some improvements there were still issues in respect of medicines. The service was not following current guidance and regulations about the management of medicines. This meant that people were not protected against the risks associated with the recording and administration of medicines. We found a breach of regulations in respect of this.

There were generally enough staff to meet people’s individual care needs and this was confirmed by the majority of staff we spoke with. There was a lack of evidence to confirm what training staff had received and some staff told us that there were gaps in their training. Some supervision sessions had taken place recently. However there was no documented evidence to confirm such supervision sessions took place on a regular basis and for all staff. Further, there was no evidence that staff had received annual appraisals about their individual performance. We found a breach of regulations in respect of this.

Some staff told us that they had not received training in the Mental Capacity Act 2005. The CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS ensure that an individual being deprived of their liberty is monitored and the reasons why they are being restricted is regularly reviewed to make sure it is still in the person’s best interests. During the last inspection in November 2014, we noted that the service had not applied to the local authority for DoLs authorisations for people. During the inspection in September 2015 we saw evidence that the service had applied to the local authority for necessary DoLs authorisations.

Our inspection in November 2014 found that people were not positive about the food provided and we saw that the quality of food provided at the home was not up to an acceptable standard. During our inspection in September 2015 people had mixed reviews about the food. During the inspection in September 2015 we saw that the food provided looked appetising and was presented well.

People who used the service and relatives spoke positively about the atmosphere in the home and we observed that the home had a homely atmosphere. Bedrooms had been personalised with people’s belongings to assist people to feel at home. We saw that people were treated with kindness and compassion when we observed staff interacting with people who used service.

The home had a complaints policy in place and there were procedures for receiving, handling and responding to comments and complaints.

During the inspection in November 2014 we found that quality monitoring systems and safety audits were not always effective or robust enough to identify problems within the service. During the inspection in September 2015 we found that the service had introduced a quality survey. We saw evidence that the service carried out medicine’s audits, however we found that these were not comprehensive and failed to pick up the serious issues on the ground floor. We also noted that there was a lack of audits for other aspects of the care in the home. For example there was no evidence of audits in respect of infection control, staff files and housekeeping. We found a breach of regulations in respect of this.

Staff we spoke with had mixed views about the morale within the home. Some staff said that the morale in the home was good but others said that morale could be better and that this had been affected by the constant change in management. Staff were however positive about the new manager.

We found 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 the report.