Background to this inspection
Updated
28 June 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was completed by one inspector.
Service and service type
Maranatha Rest Home is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. Maranatha Rest Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was a registered manager in post. The registered manager was not present at the time of inspection. The day to day management of the service was being conducted by two senior members of staff, with support by the provider.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We sought feedback from the Local Authority who work with the service. We used all this information to plan our inspection.
During the inspection
We spoke with four people who used the service and two people’s relatives about their experience of the care provided by Maranatha Rest Home. We spoke with three members of staff. We reviewed five people’s care files and three staff personnel files. We looked at the provider’s arrangements for managing risk, medicines management, staff training and supervision data and information relating to the provider’s quality assurance arrangements.
We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We asked the provider to send us information relating to their role and responsibilities, and to provide assurance that their oversight arrangements of the service were effective.
Updated
28 June 2022
About the service
Maranatha Rest Home is a residential care home providing the regulated activity of accommodation and personal care to up to 15 people in one adapted building. The service provides support to older people and people living with dementia. At the time of our inspection there were 15 people using the service, this included two people who were in hospital.
People’s experience of using this service and what we found
Not all risks to people’s safety and wellbeing were assessed and recorded or documented in enough detail to mitigate the risks for people’s safety. People were not fully supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Mental capacity assessments did not evidence the exact decision being assessed, the rationale why this was in the person’s best interests and had not been reviewed. The deployment of staff meant communal lounge areas were not always staffed and there was a lack of social activities facilitated.
Auditing systems were in place to assess and monitor the quality of the service, but senior members of staff were not involved in this process. In the absence of the registered manager there were no contingency plans in place to oversee the quality of the service provided. No information was available to demonstrate the provider had oversight of the service.
People told us they felt safe and relatives confirmed they had no concerns relating to the safety of their family member. Medication practices were safe, but improvements were required where people received PRN [when required] medication. Appropriate arrangements were in place relating to the service’s recruitment practices but improvements were required to ensure DBS checks were appropriate. We have made a recommendation about this. Relatives were complimentary about the registered manager and the care people received. Staff told us they felt valued and supported.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was Good [published 9 November 2021].
Why we inspected
The inspection was prompted in part due to notification of a specific incident. The information CQC received about the incident indicated concerns relating to risk management. A decision was made for us to inspect and examine those risks. We have found evidence the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
You can see what action we have asked the provider to take at the end of this full report.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.