This inspection took place on 20 November 2018 and was unannounced.

The last inspection took place on 27 June 2017 where we found no breaches of Regulation and rated the service as “Good”.

Murree Residential Care Home is a care home that is registered to accommodate up to four people who have learning disabilities and who require support with personal care. At the time of our visit, there were four people living in the home.

The home is owned and managed by Shahnaz Abbasi and therefore there is no requirement for a separate registered manager for this location. For the purposes of the inspection report, we have referred to Mrs Abbasi as the ‘manager’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission [CQC] regulates both the premises and the care provided, and both were looked at during this inspection.

We carried out this inspection on 20 November 2018 following concerns that were reported to us by the local authority. Concerns were raised in respect of the cleanliness of the home, maintenance, medicine administration, staff training, staffing numbers and the lack of activities available in the home. Prior to the inspection, the manager had attended various meetings with the local authority and other external care professionals in respect of the concerns raised and an action plan was in place to monitor the home and ensure they make improvements.

During our inspection, we found that there were aspects of the care provided that were not safe. The arrangements for ensuring that people living in the home and staff were kept safe in event of a fire were not adequate. There were some fire safety arrangements in place. These included weekly alarm checks, a fire risk assessment and a fire evacuation plan. However, during the inspection we noted that Personal Emergency Evacuation Plans (PEEPs) were not in place. These are required as they provide staff or emergency services detailed instructions about the level of support a person would require in an emergency situation such as a fire evacuation. We also noted that whilst a fire risk assessment was in place, it did not include information about the arrangements for people who smoked. We also noted that only one fire drill had been carried out in the past 12 months. We found some deficiencies in respect of fire arrangements and found a breach of regulation in respect of this.

During the inspection, we looked at the arrangements for medicines in the home. There were systems in place for obtaining and disposing of medicines and the home had a suitable medicines storage facility in place. We looked at a sample of medicine administration records (MARs) and noted that there were no unexplained gaps which demonstrated that medicines were administered as prescribed. We however found that the medicines administration policy was not sufficiently comprehensive and we discussed this with the manager who said that it would be amended.

On the day of the inspection we observed that care staff did not appear rushed and were able to complete their tasks. The manager explained that since concerns had been raised by the local authority, she had ensured that an extra member of staff was on duty during the day. However, we noted that there was one care staff on duty at night and we queried this with the manager and explained that due to people displaying behaviour that challenged the service, one member of staff may not be appropriate to effectively care for people whilst also considering the safety of care staff. The manager said that she would review this.

Risk assessments had been carried out which detailed potential risks to people and how to protect people from harm. People's care needs and potential risks to them were assessed.

The local authority had previously raised concerns about the cleanliness and maintenance of the home. There had also been concerns raised about cockroac

This inspection took place on 27 June 2017 and was unannounced. Murree Residential Care Home is a care home that is registered to accommodate up to four people who have learning disabilities and require support with personal care. At the time of our visit, there were three people living in the home.

We last inspected the home on 30 April 2015 and found no breaches of regulations and rated the home as “Good”.

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.

During the inspection we observed people were treated with kindness and compassion. It was evident that positive caring relationships had developed between people who used the service and care staff. People who used the service spoke positively about staff and the care provided at the home. People who used the service told us they felt safe in the home and around care staff.

We also found that appropriate arrangements were in place in relation to the recording and administration of medicines.

There were enough staff to meet people’s individual care needs and this was confirmed by staff we spoke with. On the day of the inspection we observed that care staff were not rushed and were able to complete their tasks.

Systems and processes were in place to help protect people from the risk of harm and staff demonstrated that they were aware of these. Identified risks associated with people’s care had been assessed and plans were in place to minimise the potential risks to people.

Care staff told us that they felt supported by management. They told us that management were approachable and they raised no concerns in respect of this. We saw evidence that staff had received training in various areas but found that there was a lack of evidence of training in relation to safeguarding procedures and medicines management. We saw evidence that staff received regular supervision sessions.

People’s health and social care needs had been appropriately assessed. Care plans were person-centred, detailed and specific to each person and their needs. Care preferences were clearly documented and included comprehensive detail. People told us that they received care, support and treatment when they required it. Care plans were reviewed regularly through key worker sessions and were updated when people’s needs changed.

People in the home had capacity to make their own decisions and care plans demonstrated that they were involved in making decisions about their care.

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. Following a recommendation made at the previous inspection, the provider had taken appropriate action to ensure that two people had necessary DoLS authorisations in place.

People spoke positively about the food arrangements in the home. They explained that they had a choice of foods and there wasn’t a set menu as people ate what they liked and when they liked. People’s weights were recorded regularly. This enabled the service to monitor people’s nutrition so that staff were alerted to any significant changes that could indicate a health concern related to nutrition.

People 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 found the home had a management structure in place with a team of care staff

This inspection took place on 30 April 2015 and was unannounced. The service was last inspected in January 2014 and was found to be fully compliant with all the regulations we checked at that time.

Murree Residential Care Home is a care home that is registered to accommodate up to three people who have learning disabilities and require support with personal care. At the time of our visit, the service was providing care for two people.

The service had a registered manager in place. 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 rights were not always protected. The provider had not made an application under the Mental Capacity Act Deprivation of Liberty Safeguards for one person, even though their liberty may have been restricted.

There were procedures in place for ensuring any concerns regarding care and safety of people were appropriately responded to. Staff understood the procedures they needed to follow to ensure that people were safe. They described the different ways that people might experience abuse and the appropriate steps to take if they were concerned that abuse had taken place.

Staff had the skills and knowledge to support people who used the service. There were enough staff available at the service. Staffing levels were arranged according to the needs of the people using the service. We saw that people received a consistent and safe level of support during this inspection.

People were supported to eat healthy foods. People told us they liked the food and they were able to choose what they ate and drank. Care plans included information about supporting people to eat a healthy diet.

People told us they were treated with dignity and respect. Staff we spoke with understood the need to protect people’s privacy and dignity. We observed staff knocked on people’s doors before they could enter their rooms. Staff understood and responded to people’s religious and cultural needs. People’s care records contained documented evidence that arrangements had been made to ensure that their religious and cultural needs were responded to.

The service carried out assessments of people’s needs to determine if they could be met by the service before they commenced providing care. This was to ensure the service was appropriate and could meet their needs.

There was a system to assure the quality of service they provided. We saw that the service was regularly reviewed. Prompt action had been taken to improve the service where shortfalls had been identified.

We carried out this inspection to check if the provider had complied with two compliance actions from a previous inspection of the service. We examined whether the provider was meeting Outcome 8: Cleanliness and infection control and was compliant with Regulation 12 and Outcome 9: Management of medicines and was compliant with Regulation 13 (Health and Social Act 2008 Regulated Activities) Regulations 2010.

At this inspection we were satisfied that people who used the service received their medication as prescribed.

The provider had developed procedures or guidance on the safe administration of PRN medicines. This meant that medicines were given to the individual appropriately because the provider had guidance to indicate at what point the medicines would be given.

We found that action had been taken to ensure that appropriate standards of cleanliness and hygiene were maintained to prevent or minimise disease and spreading of disease in the home.

We were not able to speak to people using the service because they had complex needs, which meant they were not able to talk to us. We were not able to speak with people’s relatives as contact details were not provided.

We talked with staff to check how they respected and promoted people’s dignity when delivering care. Overall they were knowledgeable about the need to protect people’s privacy and dignity.

We looked at how the service reduced the risk of people receiving unsafe and inappropriate care. We saw that the care needs of people had been assessed, together with actions for minimising potential risks.

We checked to see if people who used the service were protected against the risks of acquiring infection. The provider failed to maintain appropriate standards of cleanliness and hygiene to prevent or minimise disease and spreading of disease in the home.

We checked to see if people who used the service received medicines at the time they needed them and whether medicines were handled safely and securely. We found, although there were appropriate arrangements for ordering and receipt, the provider did not always record on the medicine administration records (MAR) when medicines were given.

Overall, the provider had arrangements to monitor and manage risks to people who used the service.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs, which meant they were unable to tell us their experiences. We observed that some people’s choices and preferences were not always taken into account because the provider did not have individualised care plans to facilitate communication in areas such as food and activity choices.

We were satisfied that people received effective and safe support because their needs were assessed along with support plans.

Staff demonstrated they understood aspects of safeguarding process relevant to them. They told us they were well supported by the management and were aware of their limitations but confident to approach managers when they needed to.

We noted the provider did not have systems to monitor the quality of the service provision.

At the time of our visit to the home, two of the three people living in the home were present. Only one of these people was able to discuss with us the quality of the care provided. We observed care practices and the interaction between people using the service and members of the staff team. This enabled us to gauge people’s satisfaction with the support they received.

Comments about the members of staff included “they talk to me respectfully” and they were “nice and friendly”. Confirmation was given that staff gained people’s consent before providing assistance and that people were involved in their care. “They tell me what is planned. I’ve always agreed with it”. People had a programme of activities in place to provide stimulation and enjoyment and programmes included college or day centre attendance and opportunities to go out shopping and to restaurants. A person said that a holiday was being planned in April to Bath and that it was “something to look forward to”.

Although not sure about the details of their plan they said that they were provided with “enough” help to meet their needs. We asked if there were sufficient staff on duty and they said “I think so. There are usually one or two”. During the visit people living in the home were relaxed in the company of the members of the staff team and there was a friendly rapport between members of staff and people using the service.

We asked people about the manner and the conduct of the members of staff supporting them. They confirmed that staff “know what they are doing” and described staff as “nice and friendly, more like mates than care workers”.

If people had any concerns they told us “I can talk to anyone including the manger and her husband or a member of staff”. We were told that “they would listen”. They said that they were happy with the overall quality of care and that “I am very happy here. It’s very good”. They told us that they would give the home a score of nine out of ten.