We carried out a review of the data available to us about Mary Rose Manor on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Mary Rose Manor, you can give feedback on this service.
At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
The service was run by a registered manager. 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.
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At this inspection we found the service remained Good.
Processes, systems and practices were in place to protect people from the risk of abuse. The registered manager ensured staff learning took place following incidents. Risks to people had been assessed and their safety was monitored. Processes were in place to ensure people’s medicines were managed safely. People were protected from the risk of acquiring an infection.
There were sufficient suitable staff to meet people’s needs. Staff pre-employment checks had been completed and the registered manager took swift action to ensure five staff without a full employment history as legally required, provided this information.
People’s care was delivered in accordance with current legislation, standards and evidence-based guidance to achieve effective outcomes. Staff were appropriately supported in their role through training, supervision and professional development. People were supported by staff to eat and drink sufficient for their needs. Staff worked together to deliver people’s care and ensured they were supported to access healthcare. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
Staff treated people with kindness, respect and compassion and provided any emotional support they needed. People were supported to express their views and to be actively involved in decisions about their care where possible. Staff ensured people’s privacy, dignity and independence were promoted.
People received individualised and responsive care that met their often complex needs. Staff provided people with sufficient opportunities for stimulation and support to pursue their interests. People were supported appropriately at the end of their life.
People’s care was underpinned by a positive person-centred culture. Staff understood their roles and responsibilities and regulatory requirements were understood and met. People’s views on the service had been sought and acted upon. Processes were in place to ensure continuous learning took place and areas of practice that could be improved for people were identified and addressed.
Further information is in the detailed findings below.
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.
People were supported by staff who had a good understanding of how to keep them safe, identify signs of abuse and report these appropriately. Robust processes to check the suitability of staff to work with people were in place. There were sufficient staff available to meet the needs of people and they received appropriate training and support to ensure people were cared for in line with their needs and preferences.
Medicines were administered, stored and ordered in a safe and effective way, work was in progress to improve protocols for as required medicines.
Most risks associated with people’s care were identified and clear plans of care were in place to ensure staff knew how to mitigate these risks. Staff had a very good understanding of these risks and how to ensure the safety and welfare of people. Incidents and accidents were clearly documented and investigated and work was in progress to review patterns and trends in these events. Actions and learning were identified from these and shared with all staff.
People were encouraged and supported to make decisions about their care and welfare. Where people were unable to consent to their care the provider was guided by the Mental Capacity Act 2005. Where people were legally deprived of their liberty to ensure their safety, appropriate guidance had been followed.
People received nutritious meals in line with their needs and preferences. Those who required specific dietary requirements for a health need were supported to manage these.
People’s privacy and dignity was maintained and staff were caring and considerate as they supported people. People were encouraged to share their views of the home at meetings and through questionnaires. Information from these was shared on noticeboards in the home.
Care plans in place reflected people’s identified needs and most of the associated risks. A new format of care plans had been introduced to provide clear and concise plans of care in line with people’s needs and preferences.
Staff were caring and compassionate and knew people in the home very well. External health and social care professionals spoke highly of the care and support people received at the home. They were involved in the care of people and care plans reflected this.
Effective systems were in place to monitor and evaluate any concerns or complaints received and to ensure learning outcomes or improvements were identified from these. Staff encouraged people and their relatives to share their concerns and experiences with them.
The registered manager was very visible in the service and provided strong and effective leadership. They promoted an ethos of open and honest communication within the home. Staff felt respected and valued in the home and this was reflected in the way they supported each other and promoted person centred and efficient care for people.
A robust system of audits was in place at the home to ensure the safety and welfare of people. Any actions required from these audits informed an overall action plan for the home which was monitored and actioned by the registered manager and registered provider.