Archived: Marland Court

On this page

• 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 inspection we rated this key question requires improvement. At this assessment the rating has remained 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 people’s safe care and treatment as the service had not identified specific risks posed to people; staff were not provided with information on how to best manage or mitigate risks.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always work well with people and healthcare partners to understand what being safe meant and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect.

The accident and incident log we saw was not fully completed; themes and patterns could not be easily identified and acted upon to help prevent repeat incidents. People were not always safe from harm whilst living at Marland Court.

We discussed safeguarding with members of staff. The information and examples they provided showed an understanding of their responsibilities and how they should report concerns.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

A person’s medication care plan indicated that they had historic addictions involving medications, drugs and alcohol and these affected their health and well-being. There were no risk assessments in place relating to these addictions, nor how staff might manage the person’s behaviour in the event of any challenge or distress.

A younger resident was on long-term respite, admitted from hospital following a stroke and a recent operation. This called for specific moving and handling practices to ensure they remained safe. Their Health - Mobility care plan stated, “I need to wear my helmet during all movements in the hoist or on the bed”, however staff were not given a rationale for this. There were no risk assessments outlining the right course of action for staff and the risks posed to the person.

Where people were known to pose a risk, or did not respond well to certain staff members, sufficient preventative measures were not taken to mitigate these risks, and ensure the person was not placed in difficult situations to keep all involved safe. We were made aware of an incident that occurred between our 2 site visit days where a member of staff had been assaulted by a resident. A similar altercation had occurred a few days previously, involving the same person.

Relevant risk assessments had not been reviewed or updated following these incidents. There was no briefing to staff or reflections on what could have been done better. Staff were not provided with information and techniques on how to best manage people’s complex behaviours and therefore incidents were more likely to re-occur. A member of staff we spoke with told us, “We can see care plans and risk assessments on the handheld devices, but they are never updated and there are hardly any risk assessments. They're never done or updated.”

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.

The manager told us the lift in the home was out of action and had not been used for 12 months, but it was unclear why this was the case. People living upstairs in the home were aware not to use the lift, but we saw nothing documented in resident meetings to remind people about this.

We saw access to a set of stairs from a corridor on the ground floor. This led up to another room that was undergoing renovation. The stairs and the bedroom were accessible by people walking along the corridor. The provider had not taken this into consideration, nor had any risk assessments been completed regarding people’s access to the stairs.

During a walk around the home, we observed some risks to the environment (such as unlocked doors leading to potentially hazardous items) which had not been identified by the service. We fed this back to the area manager at the time of the assessment, who told us they would resolve the issue.

The environment was restrictive for some people living at the home who mobilised using larger wheelchairs. At the time of our assessment, we observed one person living at the home struggling to enter their room in their wheelchair. We were later told by a relative that due to the environment their relative had not had a shower for a significant amount of time.

Health and safety checks had been carried out, and the service was compliant, for example regarding fire safety, gas safety and electrical equipment testing. There was a system in place to manage maintenance of the building; work was required to the outside space to make it safe and secure for all.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff did not receive support in the form of continual supervision, appraisal and recognition of good practice. Supervision did not take place regularly. The provider had not always checked staff's competency to ensure they understood and applied best practice in their support. We did not see any evidence that staff had been provided with the opportunity for an annual appraisal.

We observed staff being kind and caring and responding to people’s needs when required. However, staff did not always have the time to spend with people unless they needed something. We received mixed feedback about staffing levels with one relative telling us, “More staff are needed to provide better care”; another relative told us, “The staff are responsive on the days that I visit; there is always someone looking out for her.”

Safe recruitment processes were not always followed. The provider did not always follow its recruitment policy. Some staff members only had references from family friends, with no records of employment references or references from professionals being recorded, which meant we were not assured, the provider had robustly assessed their character. The provider had an ongoing recruitment plan in place; this included the recruitment of staff from overseas.

A number of long-standing staff had recently left, therefore the home relied heavily on overseas staff at the time of this assessment. We did not see any contingency plans in place should these staff members leave the service. The service was currently in the process of recruiting at the time of the assessment.

Staff told us they liked working at the service and felt they received the required training and support needed to meet their role and responsibilities; however, we identified this training did not include subjects listed as the types of support offered by the service such as complex dementia care, mental health and substance misuse.

The provider did not always properly assess and manage the risk of infection. There were dedicated domestic staff and cleaning schedules were in place, although some people were reluctant to have their personal spaces cleaned. Whilst refusals for this were recorded it wasn’t clear how often or when this was escalated to ensure people were protected from the potential spread of infection.

We detected an odour in one of the bedroom’s and brought this to the manager’s attention. The room was vacant at the time of the inspection and the provider was working on upgrading the room, having removed the carpet. They planned to replace this with a laminate-effect flooring for ease of cleaning and to help promote good infection control.

Cleaning of equipment, such as hoists and wheelchairs, was carried out by night staff and labelled accordingly once cleaned. We observed most areas of the home to be clean and tidy. Staff cleaned people's rooms each morning and when required. We observed staff wearing appropriate PPE.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences, although the medication policy in the medicines room was generic and reflected a policy for a care home delivering nursing care. This needed reviewing and amending to accurately reflect the service. We did not see evidence of people being involved in choices about medication or informed when changes happened. Nor did we see any discussions or referrals to health professionals in the event of one person regularly refusing to have prescribed creams applied.

There was an electronic system for the administration of medication records (MARs). Medicines were stored correctly and the system for booking in and administering medication was effective. Staff had received the necessary training in medicines and were confident in administering medication. The medicine room was visibly organised and tidy, with arrangements in place for medication returns to the pharmacy. End of life medicines were in stock and stored appropriately, as per the controlled drugs policy.