This inspection took place on 01, 02 and 10 August 2018. The first day of the inspection was unannounced.

Miranda 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.

Miranda House accommodates 68 people in one purpose built building. On the first day of the inspection, there were 54 people living at the home. The home was registered to support people living with dementia and their nursing needs, over the age of 65 years.

People’s bedrooms were located over two floors. Each floor had a separate lounge, ‘quiet’ lounge, a dining room and adjacent kitchenette. Bedrooms had en-suite facilities and there were communal bathrooms and toilets. There was a central kitchen and laundry room.

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. The registered manager was available throughout the inspection.

This service has a poor history of compliance, as this was the third time the service had been rated requires improvement. At the last inspection in July 2017, two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. These had not been fully addressed, which meant at this inspection, there were two repeated breaches and an additional breach in regulation.

The provider had a range of action plans to improve the service. Much of the work was “in progress”. The action plans did not consistently give specific timescales for the work to be completed. This did not enable development to be “kept on track” or monitored to ensure sufficient progress was being made. The plans covered areas such as the environment, person centred care, care planning and the development of social activities. Additional support and resources had been allocated to the implementation of the action plans.

Risks to people’s safety were not being properly identified and addressed. For example, water from a hand wash basin in a communal toilet was excessively high and there were locks on bedroom doors that were unsafe to use. These were addressed once brought to the registered manager's attention. There was a trailing lead, which a person precariously stepped over and a heater in the dining room that had protruding edges, which increased the risk of injury if fallen against.

Medicines were not safely managed. Information about “as required” medicines was limited and staff were crushing some medicines without the prior approval of a pharmacist. Information was not sufficiently detailed or up to date regarding medicines to be taken covertly. Covert medicines are when medicines are disguised in food or drink, without the person’s consent or awareness.

The environment was not conducive to people’s dementia care needs and did not promote good infection control. The layout of the home did not enable easy orientation and there was limited signage or points of interest to assist people when moving around. Items such as skirting boards and some furniture was chipped. This did not enable the surfaces to be properly wiped to be hygienically clean. The provider told us they had recognised improvements to the environment were needed and were taking action to address this.

Staff did not always have a clear understanding of people’s needs. For example, staff did not sufficiently support a person who was agitated and a lunch time meal was chaotic, due to its lack of organisation. Records did not always show challenging behaviour was effectively managed.

There were sufficient staff to support people. There was a s

Miranda 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.

They are registered to provide accommodation which includes nursing and personal care for up to 68 older people, some of who are living with dementia. At the time of our inspection 50 people were using the service. The bedrooms were situated over two floors. There were communal lounges and dining areas with satellite kitchens on each floor with a central kitchen and laundry. People also had access to a communal garden on the ground floor.

We undertook an unannounced focused inspection of Miranda House on the 28 and 29 November 2017 This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive inspection in July 2017 had been made. The team inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection

At the last comprehensive inspection in July 2017 we identified the service continued to be in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not being stored at the correct temperature. During this inspection we found that these improvements had been made and medicines were being stored safely.

Some areas of medicines management required further improvement. Monitoring systems in place for the safe administration of medicines had not identified gaps in recording. Photographs of people using the service at the front of medicine administration records (MARs) had not all been updated and some photographs were missing. Decisions to administer medicines covertly to some people had not been regularly reviewed.

Some areas of the home had damaged paintwork which made them difficult to clean. Poor cleanliness in clinical was rooms was observed during our inspection. We have discussed this with the regional manager and registered manager. They said there was a renovation plan in place for the new year which would address the areas of infection control we had identified. They also took some immediate action during our inspection to resolve some of the damaged areas. Staff had access to appropriate protective equipment, such as disposable gloves and aprons to protect people with the prevention and control of infection.

Risks to people’s safety were assessed and guidance on how to minimise these risks was put in place for staff to follow. Processes were in place to safeguard people from abuse. However, staff’s understanding of safeguarding and what constituted abuse was not always consistent. Staff were aware of their responsibility to report concerns.

A dependency tool was in place to assess the level of staff that were required. The service's

staff rota demonstrated the assessed levels of staff had been provided, with cover being filled by staff completing extra shifts or the use of temporary agency staff. Safe recruitment practices were being followed.

The provider regularly assessed and monitored the quality of care provided. However, quality assurance systems had not always identified the shortfalls highlighted in this inspection.

Feedback from people and their relatives was encouraged. The registered manager and regional manager had identified improvements that were needed in the service and had plans in place to implement them.

Systems were in place for

Miranda House is a care home which provides accommodation and nursing care for up to 68 older people. At the time of our inspection 53 people were resident at the home.

This inspection took place on 13 and 14 July 2017 and was unannounced.

At the last comprehensive inspection in September 2016 we identified the service was not meeting Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not being stored at the correct temperature and some tablets had not been disposed of before their expiry date. The provider wrote to us following the last inspection to say they would take action to address the management of medicines by November 2016. During this inspection we found that these improvements had not been made and medicines were still not being stored safely. This was a continued breach of the regulation.

The registered manager had identified that work was needed in relation to storage of medicines and had raised this repeatedly through the provider’s reporting processes. Despite this being identified as a breach of regulation at the last inspection, the provider had not ensured that action was taken to store medicines within the safe temperature range. Whilst the quality assurance systems had identified shortfalls, the process to ensure those shortfalls were rectified when the work required additional expenditure or building works was not effective. This had resulted in people using the service being placed at risk of receiving medicines that had been compromised and were not effective.

We observed some positive interactions between staff and people using the service. Generally staff were friendly and the atmosphere was calm and relaxing. We heard staff singing with people and laughing with them. However, we observed some occasions when staff did not respond to people’s request for support and reassurance.

Relatives gave mixed feedback about the staff. One said “The managers and the carers are all lovely. They’re very caring and loving to me and my relative. They’re like my extended family, I love them all”. Comments from other relatives included “Some carers are lovely, absolutely wonderful, but others are a bit iffy” and “It’s not the Ritz, but I keep my relative here because of certain care staff who are lovely”.

Staff were taking suitable action when they identified that people did not have capacity to consent to their care or treatment and had made applications to authorise restrictions on people’s liberty. Where restrictions had been authorised with conditions, the registered manager had reviewed the actions they had taken to meet the condition.

Risks people faced were being well managed. Staff had identified risks people faced and had planned with them how those risks should be managed. Staff had a good understanding of the risks and the action that was planned. The plans were regularly reviewed and updated when people’s needs changed.

People’s records contained care plans relating to their specific needs and there was evidence that the plans were updated when people’s needs changed. People and their relatives told us they were involved in developing and reviewing their plans. Where people were not able to tell staff what care they needed, there was a record of who had been involved in making decisions.

Staff told us they received training and support which gave them the knowledge and skills needed to do their job effectively. Comments included “I did the Living in my world training a few weeks ago; it was about putting ourselves in the shoes of people we care for. It was really good” and “I’m doing the Care Certificate”. Nurses said they had access to professional development in order to meet their registration requirements.

Staff generally spoke highly of the registered manager. Comments included “If I speak to the manager about anything, she’s always there and will listen. She takes the time to listen” and “Our manager is excellent

Miranda House is a care home which provides accommodation and nursing care for up to 68 older people. At the time of our inspection 47 people were resident at the home. This inspection took place on 7 September 2016 and was unannounced. We returned on 8 September 2016 to complete the inspection.

At the last comprehensive inspection in October / November 2015 we identified that the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because risks people faced were not managed effectively, there were not always sufficient staff deployed in the home, the home did not always follow the requirements of the Mental Capacity Act 2005 when people did not have capacity to consent to care and treatment. In addition, care plans did not always contain up to date information about people’s specific needs and records kept by staff were not always accurate. We served warning notices to the provider and registered manager as a result of some of the concerns we identified. We completed a focussed inspection in June 2016 and found that the provider had taken the immediate action necessary to improve the service. During this inspection we found that the provider had sustained these immediate improvements, but further work was needed for people to receive a consistently good service.

People were given the support they needed to take medicines they had been prescribed and staff kept good records of the medicine they had supported people to take. Although medicines were stored securely, further work was needed to ensure they were always stored at the temperature recommended by the manufacturer and were disposed of before they reached their expiry date.

Staff were taking suitable action when they identified that people did not have capacity to consent to their care or treatment and had made applications to authorise restrictions on people’s liberty. However, where restrictions had been authorised with conditions, staff were not always clearly recording the actions they had taken to meet the condition.

Risks people faced were being well managed. Staff had identified risks people faced and had planned with them how those risks should be managed. Staff had a good understanding of the risks and the action that was planned. The plans were regularly reviewed and updated when people’s needs changed.

Staffing levels had been reviewed and there were sufficient staff deployed to meet people’s needs. During our observations we saw that staff were available to provide support to people when needed. This included support for people to eat, drink and move around the home safely. Requests for assistance from people were responded to promptly. Staff told us there were enough of them available to be able to provide safe care and meet people’s needs. Comments from staff included, “There are enough staff to meet people’s needs, which is a big improvement”, “The team works well together and there are sufficient staff to meet people’s needs” and “Staffing levels are enough to provide the care that people need”.

There was an improvement in the information set out in people’s care plans. People’s records contained care plans relating to their specific needs and there was evidence that the plans were updated when people’s needs changed. Some people told us they were involved in developing and reviewing their plans. Where people were not able to tell staff what care they needed, there was a record of who had been involved in making decisions.

People told us they were treated well and staff were caring. Comments included, “I am very happy living here. Staff treat me well” and “The staff are kind and look after me”. We observed staff interacting with people in a friendly and respectful way. Staff respected people’s choices and privacy.

Staff told us they received training and support which gave them the knowledge and skills needed to do their job effectively. Comments from staff incl

At the comprehensive inspection of this service in October and November 2015 we identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the registered manager and provider with two warning notices and five requirements stating they must take action. We shared our concerns with the local authority safeguarding and commissioning teams.

This unannounced inspection was carried out to assess whether the provider had taken action to meet the warning notices we issued. We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notices have been sustained, to assess whether action has been taken in relation to the five requirements made at the last inspection and provide an overall quality rating for the service.

This report only covers our findings in relation to the warning notices we issued and we have not changed the ratings since the inspection in October and November 2015. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. You can read the report

from our last comprehensive inspection by selecting the 'all reports' link for Miranda House on our website at www.cqc.org.uk.

At this inspection we found that the provider had taken action to address the issues highlighted in the warning notices. Risks people faced were being effectively assessed and managed. Staff had clear information about the support people needed. They demonstrated a good understanding of people's needs and the support that was required to keep people safe. Staff were following the actions listed in the risk assessments and kept clear records of the care and support they provided.

The service was meeting the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff had taken appropriate action when they assessed that people did not have capacity to make a decision. Staff had completed additional training in the MCA and DoLS and demonstrated a good understanding of the principles of the Act. People’s care records contained detailed and decision specific mental capacity assessments and the provider had made DoLS applications to the local authority where appropriate.

On the day of our visit 54 people were using the service. The majority of people were living with dementia. They were supported by two nurses, 14 care workers, catering and cleaning staff, hospitality staff and an activities co-ordinator. We spoke with two people, three relatives, six care workers, the registered manager and the regional manager. We carried out a short observation framework (SOFI). A SOFI is used to capture the experiences of people who use the service who may not be able to express this for themselves.

A single 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 care workers told us, what we observed and the records we looked at.

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?

We found the service was safe. People's relatives told us they felt people were safe. One said "I think this is a very safe home". Another said "yes they are safe. I am confident in the staff". Care workers had been trained in safeguarding vulnerable adults and were aware of their responsibilities. The service had a comprehensive policy on safeguarding and raised alerts with the appropriate authorities.

People received safe and appropriate care, treatment and support. Care was planned and delivered so that people were safe. Appropriate risk assessments were carried out and regularly reviewed.

We found that there was sufficient numbers of appropriately trained care staff on duty to support people. Care workers received training in a range of subjects that included moving and handling, safeguarding vulnerable adults and dementia care. Care workers we spoke with told us they had received the training and felt confident they could provide care and support to people.

The service did not have anyone subject to a Depravation of Liberty Safeguards (DoLS) application. This is where a person can be deprived of their liberties for their own safety. We spoke to the registered manager and they were aware of the recent Supreme Court judgement in relation to the Deprivation of Liberty Safeguards and were taking appropriate action.

They told us the organisation had a DoLS advisor who gave training and updates regarding DoLS. We saw they were booked to visit the service in June 2014 to inform staff on the latest Supreme Court judgement and what this meant for the service. This meant that the provider understood their responsibilities under the Mental Capacity Act 2005.

Is the service effective?

We found the service was effective. Some people at the home had complex needs and we saw that their needs were being met effectively. For example, one person was at risk of weight loss. They had been assessed and appropriate measures put into place to reduce this risk. This included nutritional supplements in their diet. We saw they were monitored regularly and weighed weekly. The records showed that this person had gained three Kilograms since January 2014. We also observed that other people were supported and encouraged to eat and drink and were offered meal choices and extra portions.

Care workers were able to tell us about the needs of the people they supported. For example, one person had mobility difficulties and needed hoisting for all transfers. Care workers were able to tell us this person could become anxious and needed constant encouragement and reassurance. This reflected the guidance in the care plan. This showed us that people received effective care.

Is the service caring?

We found the service was caring. Relatives we spoke with told us they thought the service was caring. One said "they are definitely well looked after here". Another said "my father is well cared for and he seems happy". During the SOFI observation we saw that people were given choices, supported to make decisions and care staff took time to understand people where they had communication difficulties. Throughout our inspection the atmosphere was pleasant and we observed many interactions between care workers and people that were caring, relaxed and friendly.

Is the service responsive?

The home was responsive. People’s needs had been assessed before they moved into the home, regularly reviewed and reflected in the care plans. We saw evidence that care workers recognised when a person’s condition changed or their health had deteriorated and sought the help and advice of other professionals. For example, we saw that appropriate referrals to GPs, falls clinic and occupational therapists were made.

Complaints were dealt with in a timely fashion in line with the provider's policy. The service also took account of people's comments. For example, it was raised at a relative’s meeting that the glass in picture frames could be a safety hazard. The service was in the process of replacing the glass in frames with Perspex.

Is the service well led?

We found the service was well led. A registered manager was in post and was visible around the home. We saw they were approachable and available to people, relatives and staff. During our inspection we looked at the quality assurance systems that were in place. The information reviewed demonstrated that the service was monitored on a consistent basis to ensure that people experienced safe and appropriate support, care and treatment. This also included regular surveys involving people, relatives, stakeholders and staff.

Miranda House provides accommodation and nursing care for up to 65 people with complex dementia needs and at the time of the inspection there were 63 people accommodated. At the previous inspection the home was found to meet the standards inspected.

This inspection was unannounced and took place on 13, 16 and 21 October 2015 and 17 November 2015

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People did not receive their care and treatment in a safe way. Risk assessments were devised for people at risk of falls, for people at risk of developing pressure ulcers (sometimes known as bed sores)and for people at risk of malnutrition. Action plans to mitigate the risk were not followed by the staff. For example, pressure ulcer dressings were not assessed according to the tissue viability wound management plan.

People were not protected from safe medicine management. Medicine Administration Records (MAR) were not signed by staff when medicines were administered. Accurate records of  the stocks held were not maintained and the temperature of the room where medicines were kept was above the acceptable range. People were prescribed a combination of anti-psychotic and medicines for agitation and to induce sleep. For some people these medicines could cause people to fall over causing harm and injury.

People were at risk from the spread of infection. Bins with lids were not provided in bathrooms, food was taken from the kitchen and from dining rooms to people’s bedrooms uncovered. Staff were not using appropriate boards to prepare breakfast and were using the same utensils to spread butter and jam on people’s toast. On our return visits we found some improvements in where staff prepared meals and we saw staff using lids on meals being taken to people's bedrooms.

People did not benefit from consistent staff supervision. Some staff did not always interact with people in a positive manner. We saw staff speak to people without eye contact or not giving the support to reduce people's levels of anxiety. We saw people entering and leaving other people’s rooms and consistently walking the corridors. Interest points were not provided and memory boxes that helped people find their rooms were empty.

Staff did not show a clear understanding of the principles of the Mental Capacity Act (MCA) 2005. For example, there was family involvement for best interest decisions when they did not have the authority to make these decisions. Consent was gained from a relative to deliver personal care to one person who refused personal care. Guidance was not provided to staff on how to manage situations when people became aggressive or violent towards staff attempting to deliver personal care.

Best interest decisions were made by staff without first assessing people’s capacity to make these decisions. Some people were placed at higher risk of falls by best interest decisions that were made. For example, taking walking aids away from a person in bed to maintain clear pathways in the event the person got out of bed.

The care plans in place were not up to date and did not reflect people’s current needs. For example, we saw people with injuries but care plans had not been developed to manage the wound. We found intervention charts which should be used to monitor the   effectiveness of the care plans were not completed as required. Daily reports were not consistent with the intervention charts. Staff had documented for some people a good intake of fluid but the intervention charts showed the fluid intake was below the recommended fluid intake.

Records were not completed accurately and in a timely manner. We saw staff recording that they had checked people at 30 minutes intervals. However the record was completed three hours later. Medicine Administration Records (MAR) were signed to show fortified drinks were administered twice daily although the stocks in place showed they had not been administered.

Quality assurance arrangements were place to assess people's safety and wellbeing. However, medicine audits had not identified poor stock control systems and  the poorly ventilated medicine room.

New staff received an induction and attended training needed to meet people’s specific needs. For example dementia awareness. Staff were supported with their roles and responsibilities. Staff with lead roles such as nutrition and End of Life had the training needed to undertake additional roles. One to one meetings where staff discussed concerns, personal development and performance took place with their line manager.

Safeguarding adult’s procedures were in place and staff attended the training which helped them identify the signs of abuse. Members of staff knew the signs of abuse and the responsibilities placed on them to report suspected abuse. Some relatives said their family member was safe living at the home.

People had a choice of meals at mealtimes and snacks were provided between meals. Fortified meals were provided to people at risk of poor nutrition. The chef consulted with people on their likes and preferences.

People were supported with their ongoing health. GP visits were arranged and people had regular optician check-ups. People were referred to healthcare professionals for specialist input. For example social workers, tissue viability nurse specialist and psychiatrists.

Activities coordinators organised activities, entertainment and outings. However, a limited number of people were benefitting from outings and activities. The activities coordinator interacted well with people and showed they had a good understanding of people’s background. We also saw some staff interacting well with people and showed they had insight in the causes of some behaviour. For example, how previous employment impacted on behaviours.

Relatives knew a complaints procedure was in place and felt confident to approach staff with complaints. The registered manager investigated complaints and responded in writing to the complainant on the outcome of complaints investigations.

The views of relatives on the standards of care at the home were sought  by the home through surveys. Three responses were received and they gave positive feedback on the care and treatment their family member received. The action plan from the surveys was to improve the questionnaires used to seek feedback on the delivery of care and treatment.

We conducted another visit on the 17 November 2015 and the staff we spoke with said there had been improvements since our previous visits. 

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is  in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.