This unannounced inspection took place on 9 March 2018.

The home was last inspected in July 2017 where breaches of legal requirement were found. The home was rated as 'requires improvement' overall.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve their rating to at least good. We found during this inspection that sufficient improvements had been made and the provider was no longer in breach of regulation.

Maryland 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.

Maryland accommodates up to 30 people in one adapted building.

A registered manager was 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.

During our last inspection in July 2017, the provider was in breach of regulations relating to safe care and treatment. This was because risk assessments relating to the health and safety of people living at the home had not always been completed appropriately. We saw during this inspection that there was a new process for assessing risk and risk management and the provider was no longer in breach of regulation.

During our last inspection in July 2017, the provider was in breach of regulations relating to governance and records. This was because some information was not recorded appropriately or clearly in care plans, and audits were not always effective when identifying issues of concern. with service provision. During this inspection, a more robust auditing system had been introduced, and records were clear and concise. The provider was no longer in breach of this regulation.

People told us they felt safe living at the home. We observed there were enough staff to provide safe, effective care.

Medication was safely managed, stored and administered. People received their medications on time.

Staff were recruited and selected to work at the home following a robust recruitment procedure. The registered manager retained comprehensive records of each staff member, and had undertaken checks on their character and suitability to work at the home.

The home was clean and tidy. There was provision for personal protective equipment stationed around the home, and staff were trained in infection control procedures.

Staff were able to describe the process they would follow to ensure that people were protected from harm and abuse. All staff had completed safeguarding training. There was information around the home which described what people should do if they felt they needed to report a concern.

The training matrix showed that staff were trained in all subjects which the provider considered mandatory to their role, and as stated in the provider's training policy. New staff with no experience in health and social care were enrolled on an in depth induction process.

Staff received regular supervision and appraisal.

People were supported to eat and drink in accordance with their needs. People, who were assessed as at risk of weight loss had appropriate documentation in place to monitor their food and fluid intake. Where specialist diets were needed for some people, the chef had knowledge of this.

The service worked in conjunction with physiotherapists, and psychiatrists to ensure people had effective care and treatment.

Everyone had records in their files relating to external appointments with healthcare professionals such as GP's, opticians, dentists or chiropodists. The outcome of these appointments was recorded in people's records.

Most areas of the home

This unannounced inspection took place on 18 & 24 July 2016.

A registered manager was 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.

Maryland is a care home which provides personal care for up to a maximum of 30 people. The care home is situated in the centre of Formby with easy access to public transport and shops. The home has three lounges, a dining room and conservatory. There is limited car parking and the front door entrance provides disabled access.

Risk assessments were in place, however, some lacked specific guidance and personalisation with regards to specific risks for people.

Some information concerning records relating to the health and safety of people living at the home were not always robust enough. Some information about falls, was available, however, the analysis of falls was not in depth enough to help prevent future occurrences. For example we saw that despite the provider taking action in response to a recent incident, they had not thoroughly documented this. This meant was there was no evidence to show what actions were taken. Also, some records such as weight, food and fluid charts were difficult to find because they were not always kept organised. Audits were in place and took into account the environment, care planning, medication and any incidents in general; however, these audits were not always robust enough as they did not identify remedial action needed.

Medication storage and stock checking was not always in line with guidelines. The temperature of the room where medication was stored had not been recorded. Dates were not recorded on open bottles of medication to show when they were first opened, and protocols where not in place for the use of as and when required (PRN) medications. Stock balances of medication were difficult to count as totals had not been carried forward. We have made a recommendation about the management of medicines.

The registered manager and the staff had knowledge of the Mental Capacity Act (2005) and their roles and responsibilities linked to this. People’s consent was recorded for most areas of care. We did highlight the wording of the mental capacity assessments the registered manager was using as they did not always make it clear which decision was being taken into consideration. We have made a recommendation regarding this.

People could not always remember whether or not they had been involved in the development of their care plans. Some care plans were signed by people where they had the capacity to do so; however care plans for some people showed no evidence of the person’s involvement. Care plans contained some information about people’s preferences and wishes for support. Information was recorded with regards to people’s backgrounds, hobbies and interests. Some of the information required further expanding to be more person centred and to show people’s involvement and how their choices influence their care.

People told us they felt safe living at the home and we received positive comments in relation to this. People also told us there was enough staff on duty at the home and there did appear to be enough staff.

There was a safe process in place for the recruitment and selection of staff. Staff were only offered positions once a DBS check had taken place and references were obtained.

Staff described the process they would follow if they felt someone was being harmed in any way, this included reporting their concerns to their line manager in the first instance, and reporting to external organisations.

Infection control procedures were evident in the home, and the provider had recently updated some of their policies in relation to this.

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This unannounced inspection took place on 25 July 2016.

A registered manager was 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.

Maryland is a care home which provides personal care for up to a maximum of 30 people. The care home is situated in the centre of Formby with easy access to public transport and shops. The home has three lounges, a dining room and conservatory. There is limited car parking and the front door entrance provides disabled access.

During our inspection our observation and the home’s rotas showed that staffing levels were consistent, however, some people living at the home, the staff and relatives told us they sometimes felt the home did not have enough staff on duty.

Processes relating to the safe administration of medications were in place within the home. We observed people being given their medications appropriately.

People and relatives we spoke with told us they felt safe living at the home.

Risk assessments were in place and personalised. These were reviewed on a regular basis for any change.

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

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

Staff had regular supervision and appraisal.

People had a plan of care in place which was personalised and contained information such as their likes, dislikes and backgrounds. As well as other information relevant to their needs ensuring they got the care which was right for them.

The registered manager and the staff had knowledge of the Mental Capacity Act (2005) and their roles and responsibilities linked to this.

Food was fresh and home cooked. Everyone we spoke with told us they enjoyed the food and got enough to eat and drink.

A process was in place for managing complaints and the home’s complaints procedure was available so people had access to this information.

People and relatives were complimentary about the registered manager and the provider.

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

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 and clear and transparent action plans when areas of improvement were identified by the audit process.

Our inspection was carried out unannounced. The inspection helped answer our five questions:

• Is the service safe?

• Is the service effective?

• Is the service caring ?

• Is the service responsive?

• Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

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

Is the service safe?

People told us they were well cared for by the staff and felt safe in their hands.

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 reduces the risks to people and helps the service to continually improve. The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards to help support people if they were not able to make decisions about their welfare or day to day choices.

Services to the home such as fire safety were maintained and service regularly to ensure people's safety.

Is the service efffective?

People’s health and care needs were assessed with them and they were involved in their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required. Where extra support was needed specialist advice was sought, for example, district nurses. We saw visitors during the inspection and they were able to meet their family members in private if they so wished.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people with personal care and day to day activities. People commented, " I only have to ask for help and the staff are here" and "You could not receive better attention".

People who lived at the home, their relatives and friends who were involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed. The completed surveys showed satisfaction for the service.

People’s preferences and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

We saw that people were supported to complete a range of daily activities and this included encouragement to carry on with preferred hobbies and interests. A person who lived at the home told us there was always plenty 'going on'. People were fully supported as their medical and personal care needs changed. People told us they had access to a range of health professionals.

People knew how to make a complaint if they were unhappy. People could therefore be assured that complaints would be investigated and action taken as necessary.

Is the service well-led?

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. The service worked in partnership with key organisations, including the local authority to support the care provision and service development. People who lived at the home told us the provider [owner] and manager were always available and managed the home well.

We spoke with seven people who lived at the home, a relative and visitor to gain their views about Maryland and the care and support provided by the staff.

People told us they were pleased with the standard of care and support they received. People's comments included, "Really good, I can't fault the help I get", "Excellent support all round" and "First class help." A relative commented on the good communication in the home and that they were always informed about their family member's welfare.

People had a plan of care. This evidenced their consent in respect of the care and support they needed and therefore staff acted in accordance with their wishes. We saw people's needs had been assessed and the care and support they received was delivered in a way that ensured people's safety and welfare.

People received their medicines as prescribed and in a safe way. A person told us they always received their medicines on time.

We found the environment suitable for people to live in. The home was warm, well lit, adequately ventilated and maintained to ensure people's comfort.

At the time of the inspection there were sufficient numbers of skilled and experience staff available to meet people's needs. People told us they had confidence in the staff's ability to care for them.

Effective systems were in place monitor the quality of the service people received. This included identifying, assessing and managing risks to ensure people's safety.

We spoke with six people at Maryland 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 Maryland.

People spoken with confirmed they were encouraged to express their views openly. They were of the opinion their views were listened to and that their opinions mattered. A relative commented that the staff, "Put people's rights first."

People informed us they had been asked about their care and treatment and understood and consented to it. People also told us had been informed about any changes made to their care, treatment and social support. People made the following comments, “The manager sat with me and went through the support I need” and “I have been involved with decisions around my health.”

People told us they were happy with the care and support they received. Their comments included, “I get the help I need”,“The staff are very good and make sure I am well looked after”,“I can see my doctor any time” and “The girls have a note in the diary and let me know when my hospital appointments are.”

Relatives told us the staff were good at phoning them when their family member was not well and being advised of any change in care or treatment. A relative said the staff "Went out of their way” to provide help and care to people at the home.

People confirmed they could spend their day as they wanted and there were no restrictions. With regards to social activities a person at the home said, “You can choose to take part in all sorts, for example, the quiz but there is no pressure, as sometimes I would prefer not to.”

People told us they were offered a good choice of meals and we received the following comment, “There is so much choice.” A relative we spoke said their family member was always asked what they would like to eat.

On the day of the site visit we spoke with people at the home.

People spoken with generally confirmed that they felt like they were encouraged to express their views openly. They said staff were friendly and were on hand to talk to. One person said, ‘’I like living here and the staff are good.’’

People spoken with expressed the view that they felt like they were treated with respect and dignity. They said that their wishes were listened to.

We made some observations of the support given to people in the shared living areas. We saw this was positive and people were well supported. A person who was being cared for in bed appeared comfortable and they confirmed that staff were available to help them.

The people we spoke with said that staff supported them well. We saw there was good communication when staff carried out care.

People said that they felt ‘safe’ and they felt any concerns would be listened to and addressed. Those we spoke with had no concerns with the general running of the home.

A relative expressed their satisfaction about the care and management of the home.

Concerns were raised with the Commission about how the registered provider administered their financial responsibilities in respect of fees for people accommodated at the home.

During our visit we spoke with a visiting healthcare professional who raised no concerns about the care and support offered to the people who lived at Maryland.

We observed people who used the service being supported in a respectful and sensitive manner. People spoken with during the visit told us they knew who to speak to if they felt worried or unhappy. They provided the following comments:

"I haven’t lived here very long but I have found everyone very helpful and I am looked after very well. If I had any concerns I would talk to one of the senior carers and I believe they would sort any problem out.”

“My family are very close to me and visit regularly if I was worried about anything I would talk to them and they would talk to the staff.”

People spoken with during the visit told us they thought the staff team were very kind but felt they were not involved in how the home was run.

Most people who live at the home told us they like it there and are happy with the care and support. They said the staff team are kind, caring and attentive. Some people said the home has not been as good since a change of ownership about 18 months ago. We spoke to females who live at the home who expressed concern that they had not been informed when a male joined the staff team.

Not all people were happy that baths times had been moved from the morning to evening and said that they were not given a choice in the time they have a bath.

There were mixed views about the quality of food. We heard from people who were happy with the food. Others said the quality and portion size of the meals was variable throughout the week.

Although we were told that there are times when staff seemed rushed, generally the view from people living in the home was that there is enough staff on duty for each shift. They said staff respond quickly to requests for support and they rarely have to wait too long. A relative said that staff do not have as much time to spend with the people living at the home since the staffing levels have been reduced.

We spoke to a number of people living at the home about medication. All told us they receive their medication when they need it, and receive it from staff trained to give out medication.

People living at the home were not sure how they could provide feedback on the quality of the service. Some people mentioned resident meetings but could not recall a meeting taking place for awhile. Relatives told us that they did not think a formal system was in place for either people living at the home or their representatives to provide feedback about the quality of the service.