Essex Care Consortium - Marks Tey

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to infection prevention and control, and staffing in relation to training and safe recruitment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety. Systems for recording incidents, accidents, and safeguarding concerns were not always used effectively to support learning or to improve outcomes for people. Safety incidents were being reported and recorded but did not demonstrate a full review of the incident was considered to identify root causes, inform future actions to mitigate risk and improve outcomes for people. For example, the monthly accident analysis for September 2025, identified there had been 1 fall, however there was no information about who the person was, the consequences of the fall, and what, if any, lessons were learned to prevent further falls.

While the registered manager had improved individual behaviour incident analysis, there was still no effective oversight of service wide themes or trends. Monthly behaviour reviews identified patterns for each person, but these were completed in isolation and did not contribute to an overarching analysis of incident frequency, such as the use of ‘as required’ (PRN) medicines, or emerging issues across the service. Although the service improvement plan (SIP) created by the registered manager dated 1 July 2025 recognised the need to strengthen incident reporting and analysis to reduce incidents, there had been no subsequent review to determine whether the actions taken were effective. However, staff told us they were encouraged and supported to raise concerns. One member of staff told us, “Never any issues reporting incidents to managers. We have on call, and we can always contact the manager. They are very good.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Safety and continuity of care was seen as a priority throughout people’s care journey including when they moved between services. The registered manager and staff worked well with other healthcare professionals, social services, and commissioners to support people’s pathways and transition to the service. There was a clear focus on improving people’s lives when moving into the service while protecting their right to live in safety, free from the risk of abuse, avoidable harm and self-neglect. Where issues about a person’s safety had arisen during their transition into the service, the registered manager had shared concerns with other professionals quickly and appropriately.

Managers and staff effectively planned and coordinated people’s care in collaboration with partners and the wider community, ensuring continuity of care, treatment and support. People had personalised hospital passports so that important information about their needs and preferences could be shared with other services, such as during hospital admissions, to ensure they received appropriate care. We received positive feedback from external professionals about how the service worked with them. Where a person’s health had significantly deteriorated a health professional told us, “The service had worked well with health professionals in the acute setting, the community and with NHS continuing healthcare (CHC) to arrange a complex discharge and showed compassion and advocacy for the person. They worked hard to maintain contact between all the services and worked collaboratively to ensure a safe discharge.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Managers and staff shared concerns quickly and appropriately. Staff had a strong understanding of safeguarding and the action they would take if they identified or had an allegation of abuse reported to them. Comments included, “I have completed safeguarding training and am aware of the types and signs of abuse, including financial, physical, including conflict between residents and risks associated with absconding. I have never had to raise a safeguarding but would feel comfortable to raise,” and “I have regular supervision with the manager or supervisor and discuss safeguarding, including how, and who to report to. I would raise concerns with the local authority safeguarding team outside of our organisation.”

The registered manager had a clear understanding of safeguarding systems, processes and practices to protect people from abuse, including financial abuse. They had made appropriate referrals to the local authority and CQC sharing information about people who had experienced abuse or were at risk of abuse in a timely way.

People were supported to understand what keeping safe means. Posters were displayed in the service, which meant that important information such as internal and external safeguarding contacts were available to staff and people living at or visiting the service should they need to share any safeguarding concerns about themselves or others. The service was operating in accordance with the deprivation of liberty safeguards (DoLS). The registered manager demonstrated a sound understanding of when a deprivation of liberty may occur and submitted applications promptly when required and, in the person’s best interests. Assessments appropriately involved family members and advocates, ensuring that individuals’ views and preferences were fully considered.

Managers and staff knew people well and understood how to meet their needs in a safe and supportive way and manage risks by thinking holistically. The service had an ethos of positive risk taking as opposed to avoiding risk which helped to ensure people had choice and remained as independent as possible. People were involved in making decisions, including managing risks to their safety and planning for their future. Risk assessments were person-centred, proportionate, and regularly reviewed to ensure they remained relevant. These ensured staff supported and empowered people to take risks, which respected their choices, and kept them safe whilst engaged in activities that mattered to them, such as cooking, using appliances and accessing the community. We received positive feedback from relatives about how the service supported people to manage risks whilst promoting independence. One relative told us, “(Person) is at risk of choking and staff will cut up their food to enable them to eat independently, but they are always there to watch them eat”.

Where people communicated their needs, emotions, or distress through their behaviour staff had managed these situations in a positive way, which protected people's dignity and rights. Behavioural tools such as antecedent behavioural charts (ABC) were in place and shared with relevant professionals involved in the persons care to help identify the cause of any distress and develop strategies to minimise future incidents occurring. The service was committed to minimising the use of restrictive interventions, including restraint and that restraint was only used as a last resort. Staff told us they had received training in physical intervention, which had provided them with the skills to deflect physical confrontations or aggressive situations safely and effectively. One member of staff commented, “I have had training in positive behaviour support (PBS) and people’s behaviour support plans give good detail how to provide support. For example, (Person) came out of a secure hospital last year a different person than the person that went in. They were like a new client, with so many layers. We are still finding new behaviours and supporting them through ongoing review and gauging how to best support.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. Arrangements to monitor the safety and upkeep of the premises were not always effective. Records showed gaps in some health and safety checks such as fire drills and legionella checks. A review of the fire logbooks for both bungalows showed that although the annual fire alarm service was completed in November 2025, the weekly fire alarm checks were frequently missed. These routine checks were essential for ensuring the fire alarm system was working, identify faults and maintain compliance with fire safety regulations. The registered manager had since retrained staff to improve their understanding and ensure weekly tests were carried out consistently. In The Laurels, only one fire drill was documented on 22/09/2025. The record lacked detail about the outcome of the drill, any lessons learned, or improvement actions required. While the registered manager confirmed that additional fire drills had taken place in both houses, they were not recorded in the logbook, resulting in incomplete documentation.

Legionella checks were essential for ensuring the safety and compliance of water systems. These checks involve evaluations of water systems to identify potential risks associated with legionella bacteria. Although a legionella risk assessment was in place and checks such as flushing of little used outlets was taking place, there were no checks being completed for temperatures of the water leaving and returning to the water storage tank. We made a recommendation during the inspection that the maintenance manager should seek advice from their external contractor about how to complete these checks. Environmental audits were being completed by the maintenance team monthly, however where issues were identified there was no information about what action had been taken to address the issues and on what date. For example, an audit completed in June 2025 identified that lights were not working and door frames needed repairs but there was no further information about whether this had been resolved. The audits had not been signed to show that they had been checked by the provider and any issues resolved.

The premises, which comprised of two bungalows and a separate flat, were designed to meet the needs of the people living there. A relative told us, “The place is well maintained and tidy. The place was painted three years ago and then before [Person] moved into their current room. The maintenance team keep the place tidy, clean and cut the grass.” People took pride in their rooms and were consulted about the environment, including how they wished their personal rooms to be decorated. During the visit we observed that people were able to navigate the home safely and with ease, including accessing the garden and external spaces.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Improvements were needed to ensure recruitment processes demonstrated that staff were suitably experienced, competent and able to carry out their role. Recruitment checks such as DBS, sponsorship documents, and references were obtained, but gaps in employment were not always explored. Exploring gaps in employment is an essential step for safeguarding and assessing suitability of staff in adult social care. Skills tests were introduced to assess applicants’ competence, but interview records did not always show that responses were explored in sufficient depth. For example, one applicant’s written response to a safeguarding scenario was incomplete and demonstrated limited understanding, yet no follow-up questioning or evaluation was documented to assess their suitability or identify learning needs.

Staff reported receiving effective support, supervision and development, and worked well together to deliver safe, person-centred care. However, actions agreed in supervisions were not always followed up. For example, one staff member requested training in end of life care, but it had not been provided. Staff told us they felt they would benefit from further training in specific mental health conditions experienced by the people they were supporting so they could better understand their experiences and how best to support them. The registered manager told us they were currently looking into additional positive behaviour training for staff.

Staff told us they had received relevant training for their roles, however, records showed gaps remained in key areas of training needed to meet people’s changing needs, including fire safety and end of life care. Only one member of staff had up to date fire marshal training. We were told by the registered manager that training had been requested for staff, but this had not been scheduled at the time of the inspection. One member of staff commented, “The manager checks all our training is up to date, also our training needs are discussed in supervision. We have medicines competencies and moving and handling about 3 monthly to ensure we are working withing guidelines. We are all trained in epilepsy, administering buccal midazolam, and dysphagia. I am a dysphagia champion, and my role is to oversee food preparation to ensure it is prepared at the right level and consistency in accordance with people’s dietary needs. I had additional face to face training with a paramedic trainer in dysphagia.”

New staff were positive about their induction and told us that it prepared them well for the role and gave them the skills and understanding of how to support people well. A staff member told us “I did a lot of training before I started. I was sent a link to all online training. I had 2-week induction across both houses and met all the clients. My induction was amazing; I was shadowed for 2 weeks.”

Relatives told us previously there had been a high turnover of staff, but now there were consistent and familiar staff supporting their family members which was good for their wellbeing. Comments included, “There is a mix of overseas workers but more settled for two years now with staff understanding procedures. Two of the previous staff have also returned to work here,” and “The staff turnover seems to have stayed the same. All the staff are friendly.” We observed staffing levels were sufficient to meet people’s needs including 1 to 1 hours. However, the dependency tool developed to show the mix of staff skills required on each shift was not accessible to the registered manager. This meant that the skills mix of staff could not be reviewed if people’s needs changed. It had not highlighted the need for a fire marshal to always be on duty. This meant there was a risk that staff on duty could not respond safely in the event of a fire.

Where people received 1 to 1 support staff’s skills and experience had been matched to the needs of the person to enable them to work towards and achieve their aspirations and potential. The nominated individual (representative on behalf of the provider) told us, “We try to recruit staff who have common interests with people using the service. For example, 1 person loves bird watching. One of the staff is also a keen bird watcher so they go out together.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading infection. Premises were generally clean and tidy; however, environmental audits had failed to identify remedial works needed to address the poor condition of bathrooms and showers in both cottages. The shower and toilet in The Laurels had mould on the window and fan light. The net curtain also had signs of mould. Mould is a living organism; a type of fungus which can be harmful to people, causing allergic reactions, respiratory issues like asthma and infections, and irritation. Additionally, the flooring in the bathroom and toilet had a build-up of dirt in the grouting between tiles. The shower room in The Vines needed attention where the floor was coming way from the skirting, leaving a gap creating a risk for bacteria and other microorganisms to develop, potentially leading to an increased risk of the spread of infection.

An infection prevention and control (IPC) policy was in place, but this was not being followed. The policy stated the registered manager and nominated individual were the designated infection prevention and control (IPC) leads, and responsible for infection prevention (including cleanliness) management at the service, and to oversee local prevention of infection policies and their implementation. Other than cleaning check lists completed by staff daily and checked by the registered manager, there was no robust auditing processes in place to ensure infection control was being managed in line with best practice guidance and current legislation to protect people from the risk of acquiring infections. The registered manager was signposted to the local integrated care board(ICB) for support in this area during the inspection. We observed staff practicing good hand hygiene and using personal protective equipment (PPE) when required for tasks, for example when administering medicines. We saw posters for good hand hygiene displayed around the home. Food was stored safely in the kitchen and storage spaces such as cupboards.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. PRN medicine protocols lacked clear guidance on the supportive or deescalation strategies that must be attempted before administering PRN medicines for anxiety or distress. PRN protocols should set out appropriate alternative support and person-centred interventions before medication is considered. Examples include offering reassurance, using distraction or calming activities, supporting the person to move to a quieter environment, or using personalised comfort measures based on their care plan. This shortfall had also been highlighted at the previous inspection.

We observed staff administering medicines in line with policy and people’s documented preferences. We checked the balance of people’s medicines which were correct according to their records, this assured us people were receiving their medicines as prescribed. Staff had received training followed by a programme of competency assessments to check their practice was safe. Medicines audits were completed by the registered manager which meant any issues could be identified and addressed.

People’s medicines care plans contained personal statements which reflected they had been involved in in discussions and decisions about the support they needed to take their medicines. For example, 1 person care plan stated, ’I prefer for staff to help me with my medication as they know what they are doing.’ We also observed one person requesting their medicines from their own container instead of the 1 brought to their room by staff, staff respected their choice and preference and administered the medicine safely from the requested pot. Topical treatments such as creams and ointments were dated on opening to ensure they were used within the prescribed time frame, and medicines records included information for staff about the service’s policy for usage of these medicines.