Lotus Care Marmaduke Street

Updated 28 February 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection team consisted of 2 inspectors and a medicines inspector.

Service and service type

Lotus Care Marmaduke Street is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Lotus Care Maramaduke Street is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations. At the time of our inspection there was not a registered manager in post.

Notice of inspection

The inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We viewed 4 peoples care plans, 3 staff recruitment files and other documentation relating to the running of the service. We spoke to 4 staff including the interim manager, senior leadership team and 2 care staff. We spoke to 3 people who lived at the home and 1 visiting relative. We spoke with a visiting healthcare professional. We viewed multiple medication records and we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 28 February 2024

About the service

Lotus Care Marmaduke is a care home which provides accommodation and nursing care for older people some of whom were living with dementia. The service accommodates up to 48 adults. Accommodation is provided over two floors. At the time of our visit, 38 people were living there.

People’s experience of the service and what we found

Some training courses were not completed and required improvement. Some medical professionals had raised communication and competency as an issue before we inspected. The provider had started to address this. Some records were in the process of being re-written in preparation for transferring over to an electronic system.

There was a range of audits completed which had already identified the need for some improvements and there was a detailed action plan in place to address this however there were still some gaps in records. There was not a registered manager in post, however staff spoke positively about the interim manager. Staff and people who lived at the home were engaged with via regular meetings. The provider worked closely with the local authority and safeguarding adult team. The provider was aware of their obligations under duty of candour to be open and honest regarding any failings in the service and had informed CQC of any notifiable events.

People we spoke with said they felt safe living at the home. Risk assessments were in place and they were robust, informative and reviewed regularly or when someone’s needs changed. The home was clean and there were good infection prevention control procedures in place. Medication was managed safely and there was enough staff on shift to ensure people were supported safely. There was a process for assessing incidents and accidents, and these were reviewed by the provider for emerging patterns and trends.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (27 November 2020).

Why we inspected

This inspection was prompted by a series of concerns shared about the service with regards to medication management, risk assessments, staffing, staff knowledge and skills and end of life care. A decision was made for us to inspect and examine those risks. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements. We found during this inspection the provider needed to make some improvements.

Enforcement

We have identified breaches in relation to governance and records.

Please see the action we have told the provider to take at the end of this report.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Lotus Care Marmaduke Street on our website at www.cqc.org.uk.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.