An unannounced comprehensive inspection took place of Margaret Roper House on 14 & 15 November 2017.

The previous inspection was conducted on 8 March 2017. This was a focused inspection to follow up on two previous breaches for the safe administration and management of medicines. At that inspection although we found some improvements we raised a new concern around the management of medicines for people outside of the care home. For example, people going on 'home leave' or for trips out from the care home. Medicine audits (at service and senior management level) were completed, however, monitoring and audit arrangements for supporting people to receive their medicines when outside of the care home were not robust to assure people's health and wellbeing. The existing audits and governance arrangements had not identified the shortfalls we found during this inspection.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the administration and management of medicines for people who were taking their medicines out of the home to at least good. We found at this inspection that improvements had been made to ensure this practice was adhered to safely to enable people to take their medicines outside of the service. A policy and procedure was in place which staff understood and followed. Medicine audits were completed to ensure the safe management of medicines in and outside of the care home. This breach of regulation was met.

Margaret Roper House 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. Margaret Roper House provides nursing care and accommodates people who have mental health care needs. The accommodation is registered for 23 people. The registered provider (owner) is Nugent Care.

There was a new registered manager in post at the time of our 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’.

People's needs were recorded in a plan of care. Where a change in a person's needs had been identified their care plan was updated to reflect this. Information was made available to people in an accessible format.

Care records showed that people's health care needs were addressed with appropriate referral and liaison with external health care professionals when needed.

People's medicines were managed safely. Staff received medicine training to ensure they had the skills and knowledge to administer them.

Risks to people’ safety were assessed and risk management plans were in place to support people safely.

The environment and home’s equipment were maintained and subject to safety checks and service contracts.

Staff knew the different types of abuse and how to recognise and report any concerns they had.

Staff were aware of how to respect people’s rights to independence and staff told us how they empowered people to make their own decisions where able.

When people were unable to consent, the principles of the Mental Capacity Act 2005 (MCA) were followed. This included an assessment of a person's mental capacity and decisions made in the person's best interest. This could be further developed by better evidencing assessment around individual decisions for people.

People's consent was obtained prior to the delivery of any care and support though this was not consistently recorded in people’s plan of care.

People told us they were able to make individual menu requests and that their dietary needs were met by the staff. People were complimentary regarding the menu choices

We carried out an unannounced comprehensive inspection of this service on 21 September 2016 and 18 October 2016 when we found two breaches of regulation. One was a continued breach regarding the management of medicines and one a breach in respect of a lack of monitoring arrangements for medicines. At this inspection we found a number of improvements however people were still not fully protected. This was because the provider's arrangements to manage medicines were still not consistently followed.

We asked the provider to take action to address these concerns. The provider submitted a provider action report which told us the improvements they had made to meet this breach.

We undertook a focused inspection on 8 March 2017 to check that they had they now met legal requirements. This report only covers our findings in relation to the specific area / breach of regulation. This covered two questions we normally asked of services; whether they are 'safe' and 'well led.' The question 'was the service effective', 'was the service responsive' and 'was the service caring' were not assessed at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Margaret Roper House on our website at www.cqc.org.uk.

There was a registered manager in post at the time of our 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.

Margaret Roper House is a nursing home registered to accommodate people who have mental health care needs. The accommodation is registered for 23 people. The home is owned by Nugent Care.

At this inspection we found a number of improvements. For example, medicine stocks were well controlled, Medicine Administration Records (MARS) were fully completed, the quantities of medicines received into the home and carried forward to the following month was clear and fully documented. The home had introduced a system in the medicines room to highlight to nurses, which medicines were to be given before breakfast and the medicine room was tidy and well organised. Regular medicine audits were also being completed to help assure the safe management of medicines.

We found however concerns around the management of medicines for people outside of the care home. For example, people going on ‘home leave’ or for trips out from the care home. For two people out on a trip during the inspection they had not received their medicines. For one person their medicine had been removed from the medicine trolley for it to be destroyed. The registered manager told us care staff were unable to administer medicines as they had not been trained to do so. For the two people who did not receive their medicines there was no record in their plan of care or record of discussion with GP around not giving their medicines as prescribed. One of the two people went out on ‘home leave’ and we found records of medicines being destroyed and again no record in their plan of care as to why this had occurred.

This is a continued breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Medicine audits (at service and senior management level) were completed, however, monitoring and audit arrangements for supporting people to receive their medicines when outside of the care home were not robust to assure people’s health and wellbeing. The existing audits and governance arrangements had not identified the shortfalls we found during the inspection.

This is a continued breach of Regulation 17 (1)(2)(b) 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 this report.

Margaret Roper House is a nursing home registered to accommodate people who have mental health care needs. The accommodation is registered for 23 people. The home is owned by Nugent Care and there is a registered manager in post.

We conducted a focused inspection on 21 September 2016 to check that the enforcement action, for the unsafe management of medicines, which we had taken following our last inspection of 20 April and 10 May 2016 had been met. At this inspection we identified the Warning Notice had not been fully met and therefore returned to the service on 18 October 2016 to conduct a comprehensive inspection. This meant we looked at all five domains to assess whether the provider was providing a safe, effective, caring, responsive and well led service.

The provider had a recent history of not meeting requirements regarding medication safety. We had previously undertaken a comprehensive inspection of this service in November 2015 when we found a breach in regulation regarding the safe management of medicines. After this inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 20 April and 10 May 2016 to check that they had they now met legal requirements. At this inspection we found the provider still in breach of the safe management of medicines. We took enforcement action and served the provider with a statutory Warning Notice regarding medicines not being managed safely.

The service had a 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.

At this inspection we found some improvements had been made with medication management however, people were still not fully protected against the risks associated with medicines because the provider's arrangements to manage medicines were not consistently followed.

Quality assurance systems were in place but these still did not operate effectively enough to ensure people medicines were managed safely.

People said they felt safe living at the home and were supported in a safe way by staff.

People’s individual needs and preferences were respected by staff. People told us staff were kind, caring and respectful in their approach. We observed positive interaction between the staff and people they supported.

The staff we spoke with described how they would recognise abuse and the action they would take to ensure actual or potential harm was reported. An adult safeguarding policy and the Local Authority’s safeguarding procedure was available for staff to refer to.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults.

People living at the home told us that there were sufficient numbers of staff on duty to care for them. Staffing numbers were satisfactory at the time of our inspection.

People took part in a varied social programme and people could spend time pursuing their own interests if they so wished

There was a maintenance programme and arrangements in place for checking the environment was safe. Risks associated with hazards were recorded as part of the service’s health and safety measures to keep people safe.

The menus were chosen by people who were living at the home. People were complimentary regarding the standard and choice of meals served. Specialist diets were catered for.

People we spoke with and their relatives told us that staff had the skills and approach needed to

ensure people were receiving the care and support they needed. People told us they were invited to give feedback about the home through residents’ meetings, surveys and daily discussions with the staff. Quality surveys completed by people con

We carried out an unannounced comprehensive inspection of this service on 5 November 2015 when one breach of a legal requirement was found. The breach of regulation was the provider did not always ensure the safe management of medicines.

We asked the provider to take action to address these concerns. After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on 20 April 2016 and 10 May 2016 to check they now met legal requirements.

This report only covers our findings in relation to this breach specific area / breaches of regulation. This is within the 'Safe' domain. The other domains ‘Effective’, 'Caring', 'Responsive' and 'Well led' were not assessed at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Margaret Roper House on our website at www.cqc.org.uk.

Margaret Roper House is a nursing home registered to accommodate people who have mental health care needs. The accommodation is registered for 23 people. At the time of the inspection the home had a 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 and associated Regulations about how the service is run.’

At this inspection we found that the service was still in breach of the safe management of medicines. This was because medicines were not being given as prescribed, it was difficult to see how much medication was present in the home and there was a lack of guidance and care plans for a number of medicines to be given 'when required'.

You can see what action we told the provider to take at the back of the full version of this report.

This unannounced inspection of Margaret Roper House took place on 5 November 2015.

At the time of our inspection there was a 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’.

Margaret Roper House is a nursing home registered to accommodate people who have mental health care needs. The accommodation is registered for 23 people. The home is owned by Nugent Care and there is a registered manager in post.

People living at the home that we spoke with during the inspection said they felt safe living at the home.

Staff had been appropriately recruited to ensure they were suitable to work with vulnerable adults.

People living at the home and relatives told us there was sufficient numbers of staff on duty to help them.

The staff we spoke with were aware of what constituted abuse and how to report an alleged incident.

People living at the home were not always protected against the risks associated with the safe management of medicines.

Recruitment procedures were robust to ensure staff were suitable to work with vulnerable people.

Systems were in place to maintain the safety of the home. This included health and safety checks of the equipment and building.

The home had aids and equipment to meet people’s needs and promote their independence.

We found the home to be clean and staff were following good practice guidelines for the control of infection and food preparation.

Staff told us they were supported through induction, regular on-going training, supervision and appraisal. A training plan was in place to support staff learning. Staff told us they were well supported in their roles and responsibilities.

The registered manager and staff had knowledge of the Mental Capacity Act (MCA) (2005) and their roles and responsibilities linked to this. Staff support was available to assist people to make key decisions regarding their care though this was not always recorded.

Lunch was a sociable occasion for people and staff to get together. Menus were available and people’s dietary requirements and preferences were taken into account. People were offered a good choice of hot and cold meals.

People were able to see external health care professionals to maintain their health and welfare. These appointments were recorded in their care files.

People had a plan of care and information was recorded about their care needs, choices, preferences and how they wanted their care and support to be given. Risks to people’s safety were recorded and measures were in place to keep people safe.

There was a relaxed atmosphere in the home and we observed staff supporting people in a warm, caring and genuine manner. Staff were kind, compassionate and patient when talking with people. People gave us good feedback about the staff team.

During our inspection we saw staff providing care and support to people in accordance with their plan of care and when people requested it.

A process was in place for managing complaints and the home’s complaint procedure was available so that people had access to this information. People and relatives told us they would raise any concerns with the registered manager.

People living in the home and their relatives told us the registered manager was approachable and supportive.

Staff were aware of the home’s whistleblowing policy and told us they would not hesitate to report any concerns or bad practice.

Arrangements were in place to seek the opinions of people so they could provide feedback about the home. This included residents’ meetings and satisfaction surveys.

Systems were in place to monitor the standard of the service and drive forward improvements. This included a number of audits for different areas of practice. We found medicine audits (checks) were not as robust as they could be to ensure the safe management of medicines.

You can see what action we told the provider to take at the back of the full version of the report.

We spoke with six people who lived at the home and six staff who worked at the home. People told us that staff went out of their way to help them and they felt supported. Staff told us that they loved working at the home. During out visit we observed positive relationships between staff and people living at the home.

We reviewed care records and found them to be comprehensive and up to date. We found that staff were able to explain escalation processes to reflect changing health needs and this was reflected in peoples health needs assessments.

We reviewed processes in place to ensure people's nutritional needs were met and found a robust system place led by the catering team to ensure that people's needs were met and that people were involved in the process.

We found that staff were knowledgeable in safeguarding processes and there were procedures in place to protect people living at the home.

We found that there were enough staffing in place to ensure that people were supported adequately. We found that there were processes in place to account for short-term staffing concerns to ensure that staffing levels were always sufficient to ensure that people were safe and supported.

We found that there were robust audit processes in place to ensure that the premises were maintained.

We spoke with five people at Margaret Roper House and they were able to tell us what it was like to live at the home and how the staff provided the care and support they needed. All the people we spoke with told us they were happy living at the home.

People spoken with confirmed they were encouraged to express their views openly. They told us they were able to choose how they wished to spend their day and a person told us they liked the fact the staff respected their independence. We saw a number of people making their own arrangements to go out from the home, as they wished. A person told us, “I like to do things on my own and the staff encourage me. The staff know what I like to do.”

People informed us they had been asked about their care and treatment and understood and consented to it. They told us they were happy with the care and support they received. Their comments included, “I love it here, it's brilliant”, “I could not have better care” and “I am really happy with the help I get.”

People told us they were happy with the way in which the home was run and that they were able to attend regular meetings so they could talk about the home and make suggestions.

Systems were in place to monitor the quality of the service and to make improvements where necessary. This ensured people benefited from safe, quality care, treatment and support.

At a previous visit, feedback from people at the home regarding safeguarding was positive. However, on this occasion we did not receive any feedback.

At this visit, we concentrated on following up on how safeguarding is managed and how staff respond to safeguarding concerns. We also reviewed how peoples' finances are managed.

The seven people we spoke with raised no concerns about the way their medicines were handled.

We visited the home as we had received some information that raised concerns about the safety of people living there. The concerns were in three areas:

• The way the service managed people’s moneys and how people living at the home are able to access their personal allowance.

• People living in the home being singled out for ‘bullying’ by staff.

• Concerns around the management of medication.

We spoke to a number of people living in the home. All of the people we spoke with were happy to be living at Margaret Roper House. They felt staff were supportive. Staff were described as ‘excellent’ and other comments received supported this. All people spoken with said they felt safe in the home and they had no concerns.

We spoke with people who lived in the home about the way their medicines were handled. One person said care workers were ‘100% great and they looked after their medicines ok.’ Another said nurses gave them their medicines when they needed them and applied their creams every day.

Although people living in the home are generally supported we did find some areas of concern with both outcome groups assessed and these are highlighted in the report.