CQC report explained · a residential care home
What the CQC found at Marian House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2022
Marian House Care Home was inspected but not rated; inspectors found strong COVID-19 infection controls, with some personal risk information missing.
This was an announced, targeted inspection on 12 January 2022. Inspectors gave 48 hours’ notice and looked at infection control, visiting arrangements and staffing pressures linked to COVID-19.
Inspectors found suitable arrangements for visitors, testing, personal protective equipment, social distancing, cleaning and safe admissions. They were also assured that visits were being supported in line with current guidance.
The home supported residents’ religious practices and had rooms available for people who needed to isolate. However, care plans and risk assessments did not say whether individual factors, such as ethnicity or health conditions, could increase the risk from COVID-19.
The home was inspected but not rated. This report therefore does not give an overall quality rating or ratings for most of the five areas CQC normally considers.
Visitor infection controls
Visitors were tested, offered PPE and given safe places to meet residents. People who were unwell or dying could receive visitors in their rooms.
“There were suitable procedures for reducing the risks of infection from visitors.” from the report
Religious and spiritual support
The home helped residents continue religious practices, including services, communion and online meetings during visiting restrictions.
“The provider had supported people to follow religious practices and meet their spiritual needs.” from the report
PPE and testing
There were good supplies of PPE, staff had been trained to use it, and residents and staff were regularly tested for COVID-19.
“There was enough PPE for staff and people living at the service (when they wanted this).” from the report
Clean and suitable premises
The building was spacious and well ventilated, with cleaning schedules, cleanliness checks and rooms that could be used for isolation.
“The layout of the building was suitable for helping to control the spread of infection.” from the report
Personal COVID-19 risks not recorded
needs fixingCare plans and risk assessments did not specify whether a person’s ethnicity, health conditions or other factors could put them at greater risk from COVID-19. Inspectors signposted the manager to add this information.
“They had not specified whether their ethnicity, health conditions or any other factors placed them at more significant risk if they caught COVID-19.” from the report
- 01Have you now recorded each resident’s ethnicity, health conditions and other factors that could increase their risk from COVID-19?
- 02How do you keep PPE supplies, staff training and testing arrangements up to date?
- 03How would visiting work if a resident became unwell or was dying?
- 04How would you support a resident to continue their religious practices and access services?
- 05What staffing pressures are you currently experiencing, and how could these affect care?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it did not rate the other areas of care. This explanation was written from the published report of 18 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2019
Marian House Care Home was rated Good; inspectors found kind, personalised care, with some medicines recording issues and caring rated lower than before.
This was an unannounced inspection on 22 July 2019. One inspector and an Expert by Experience spoke with nine people, three relatives and staff. They reviewed care records, medicines records, recruitment files and quality records, and contacted health and social care professionals.
The home was rated Good overall, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were safe, treated with kindness and respect, involved in their care, and supported to follow their interests and maintain independence.
There were some medicines recording weaknesses. Similar tablets were not always separated clearly, some staff did not record the amount of medicine given when required, and one morning medicines record had not been signed. The registered manager addressed these points during or after the inspection.
This was the first inspection under a newly registered provider. The previous rating under a different legal entity was Good, published on 1 February 2017. Caring had previously been rated Outstanding but was Good at this inspection.
Personalised support
Staff knew people well and adapted support to their wishes, routines and changing needs. Inspectors saw examples of people being helped to continue important activities and regain independence.
“Staff were responsive to people's individual needs and knew them well.” from the report
Kind and respectful care
People and relatives said staff were kind and respectful. Inspectors observed calm, person-centred interactions and staff supporting privacy and dignity.
“We witnessed them supporting people in a person-centred way, noticing when a person was on their own and offering a chat or a touch of the hand.” from the report
Activities and inclusion
People were offered activities linked to their interests and religious life. They could choose whether to join activities or take part from their rooms.
“People who used the service were supported to enjoy activities of their choice.” from the report
Staff training and support
Staff received mandatory and needs-based training, supervision and induction. Inspectors found recruitment checks were in place before staff worked independently.
“People were supported by staff who were well trained, supervised and appraised.” from the report
Quality monitoring
The provider used audits, meetings, feedback and action plans to monitor the service. Inspectors saw evidence that identified actions were completed in a timely way.
“There were systems in place for the monitoring of all aspects of the service and these were effective.” from the report
Medicines identification
needs fixingSome similar tablets were kept together in sections of the medicines boxes. Inspectors said this could make it difficult for staff to identify an individual tablet if it was refused or not taken.
“However, where there were similar tablets in a section, there was a risk staff would be unable to identify individual tablets.” from the report
Medicines records
needs fixingNot all staff recorded the amount given for medicines prescribed when needed. One person's morning medicines had also not been signed for, although the home showed evidence that the medicines had been given.
“However, not all staff recorded the amount at each administration.” from the report
- 01What changes have you made to separate similar medicines and make each tablet easy to identify?
- 02How do you now check that staff record the amount given for medicines prescribed when needed?
- 03How do you make sure every dose is signed for on the medicines record?
- 04How often are general staff meetings held, and how do you make sure all staff receive the same information?
- 05How will you support a resident who does not share or want to take part in the home's Catholic religious activities?
This was an unannounced planned inspection covering all five CQC questions and the premises and care provided; it was the first inspection under the newly registered provider. This explanation was written from the published report of 13 August 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Marian House Care Home
3 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2019
Registered with the Care Quality Commission on 9 April 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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