The inspection was carried out over a period of three days by three Care Quality Commission (CQC) adult social care inspectors and a specialist pharmacist inspector. At the time of our inspection 31 people were using the service. As some people lived with dementia, we were only able to speak with four people. We spoke with the relatives of three people and one person's representative. We also spoke with three nurses, six care and catering staff, three managers, an administration clerk and three visiting professionals. At the time of this inspection the registered manager was working out a notice period having tendered their resignation from the post on 12 May 2014. We observed how staff supported people and looked at documents including care plans, staff rotas and records relating to the management of the service.
We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer five key questions; is the service safe, effective, caring, responsive and well-led.
This is a summary of what we found. The summary describes what people's relatives and the staff told us, what we observed and the records we looked at.
Is the service caring?
Overall we found that the service was not caring. People told us that generally staff were caring and this was supported by the positive interactions with people we saw during the inspection. However, a relative told us that they experienced difficulty in obtaining up to date information and always had to ask about the person's care and well-being.
We noted that some people's care plans were incomplete and as a result significant guidance to staff on matters such as pain management were not always provided.
Staff that we spoke with were concerned that people and relatives might think that they were incapable and uncaring because the service was being supported by the Community Care Team (CCT). The CCT was in the service providing nursing support. One member of staff said, 'I know that neglecting people is a kind of abuse and I hope we don't do that'.
Is the service responsive?
The service is not responsive. The registered manager cited a reason for their resignation as the on-going failure of the provider to respond to requests to increase the number of nurses employed by the service. They felt this compromised the standard of care and treatment the service was able to provide.
Visiting health professionals expressed concern that the service did not respond promptly when people's health deteriorated or to feedback from people and their representatives. We noted a failure to refer people for specialist treatment in a timely way. This impacted adversely on people's welfare and quality of life.
The provider's complaints policy was unfit for purpose and was not confidential. As a result it had fallen into disuse and provided little or no information to assist with the improvement of the service.
We found that the service was unresponsive to people's preferences regarding food and drink and that appropriate adjustments to people's diet had not been recorded, so that their nutritional requirements could be met consistently.
During the inspection we were made aware of a serious safeguarding matter which had been brought to the attention of the registered manager. However, the service had failed to respond in accordance with the local authority guidance on safeguarding vulnerable adults and the matter had not been reported or investigated.
Is the service safe?
The service was not safe. Nursing staff from the CCT had been providing additional staff training, and care and treatment to people living in the service. This was as a result of concerns they noted in the standards of some nursing care being delivered by Marwa Nursing Home staff..
Three out of four people we spoke with told us they felt safe living in the service. A fourth person told us they had been bullied by a member of staff.
An overview of staff training was not available and we noted an over reliance on audio visual presentations identified by the provider as a requirement.. As a consequence we were not assured that staff had been trained to care for and support people to ensure their safety and welfare
CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to nursing homes such as Marwa Nursing Home . During the inspection we became aware of a person living in the service who was subject to a level of control that required authorisation, though none was in place.
Because some care plans, risk assessments and risk reduction measures were incomplete, any new staff, especially those unfamiliar with people's needs, such as agency staff, did not have sufficient guidance to ensure that they consistently and safely met all of people's identified care and treatment needs.
Is the service effective?
The service was not effective because we found inadequate numbers of nursing staff had been employed to meet people's needs. This resulted in the registered manager performing two roles and prevented them from fulfilling their primary function of providing clear leadership and direction at the service.
Although the service had recently sought feedback from people and their relatives on the quality of the facilities and services in order to help monitor its effectiveness, the 17 responses received had not been read by the provider.
We found a general lack of systems to monitor care standards and performance and the provider has allowed existing systems to fall into disuse. Staff were unsure about the threshold for recording accidents and incidents and whose responsibility this was. This meant one incident that we became aware of had not been reported to the local authority for consideration under their safeguarding guidance.
However, we saw evaluations of the effectiveness of specific care delivered, for example, in relation to resolving one person's breathing difficulties.
Is the service well led?
The new manager for the service was appointed after the Registered Manager had left the service. Therefore the service was not well led because no time had been allocated for the Registered Manger to provide an effective handover of responsibilities to the new manager.
The use of a number of systems designed to monitor the quality of treatment and care had either lapsed or been discontinued. This included, staff supervision, the storage, management and recording of medicines and the monthly compliance auditing of the service.
We noted a failure to introduce policies and effective training to enable staff to protect people's rights in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty safeguards (DoLS). The impact of this was that people were at risk of not having their mental capacity properly assessed or the legal processes may not have been correctly applied when determining what was in their best interests.
The management had also failed to explain adequately to staff the role of the Community Care Team (CCT) in supporting the nursing staff in the provision of care and treatment. This meant that Marwa Nursing Home staff perceived the CCT as a threat rather than an experienced resource they could draw up on. Because of this, we considered that the opportunity to maximise the benefit of this support may have been lost.