Maria Residential Home

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 assessment 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.
 

This service scored 47 (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. Lessons were not always learnt to continually identify and embed good practice.

The provider had not always acted upon feedback to make improvements. We found the provider was in continued breach of regulation from our previous inspection. The registered manager told us, “We recognise, that we need clearer evidence of learning from events within the home, and this will form part of our whole-service audit and improvement plan.”

However, the registered manager was able to share some examples on how they and the provider had used complaints to share learning across the staff team. Systems were in place for staff to report any concerns, falls and accidents. The provider had systems in place to monitor these to prevent a reoccurrence. However, the systems and oversight required improving.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The registered manager and provider has systems in place to ensure they shared important information with external healthcare professionals. When a person became unwell and there was a potential for them to be admitted to hospital the registered manager would attend the home to support staff. A hospital passport document (detailing health conditions) would be sent to the hospital with the person.

Relatives gave positive feedback about how their family member had been supported following a hospital admission. One relative told us, “[person] had been in hospital and came home a few days ago, but they thought [person] was ill again… [the home] saw it straight away when [person] returned and all the staff were concerned.” Another relative told us, “[staff] do phone us up when [person] is in hospital.”
 

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. The provider shared concerns quickly and appropriately.

The registered manager and staff were aware of how to recognise situations which expose or increase people to abuse. Where staff had identified safeguarding concerns, referrals had been made to the local authority for them to consider if a further enquiry was needed. The registered manager had worked with the local authority safeguarding team to ensure people were protected from abuse.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider was aware of their responsibilities to apply to the supervisory body (local authority) when a person was not able to consent to live at Maria Residential Home. There were systems in place to monitor applications made.
 

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.

Risks to people were not always assessed, monitored or mitigated effectively. Care records identified 2 people required 2 staff for transfers and repositioning, to ensure they were protected from a deterioration in their skin health. However, staffing records showed periods when only 1 member of staff was rostered to work at the home, and daily notes did not consistently demonstrate repositioning was completed at the frequency set out in people’s care plans and risk assessments. Records also showed repeated observations of redness. This meant the provider failed to ensure people received the support required to reduce the risk of avoidable harm and deterioration in their skin health.
 

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 provider supported people to experience care and support in an environment which replicated a person’s home. However, they did not always identify all hazards to people and had not fully assessed risks posed to people. On day one of our visit 1 person was routinely seen in the kitchen area after a meal had been cooked on a stove, in addition a fat fryer had been used. Although we saw staff were also present in the kitchen area, no risk assessment was in place to identify potential harm to the person, or staff. We discussed this with the registered manager who stated staff are always present when the person was in the kitchen. The provider was asked to consider the need for a risk assessment.

Staff were supported to understand their role in the event of a fire. However, the provider and registered manager had not ensured equipment held within an emergency grab bag was in working order. For instance, one emergency grab bag we checked had an unopened torch and gas horn, the registered manager told us they would check the bag yearly. We found no communication device (phone or similar) was in place for staff to use. This has the potential to put people at risk in the event of a fire as equipment was not checked frequently to ensure it was in working order.

The registered manager was aware of the requirements to ensure the premises were safe for people to live in. Records relating to the required checks demonstrated compliance. For instance, we found safety certificates were in date.
 

The provider had not assured itself sufficient numbers of suitably skilled staff were deployed to meet people’s assessed needs safely.

Rotas showed only one member of staff was rostered to work at the home during identified periods, although the care plans and risk assessments for 2 people stated 2 trained staff for transfers and repositioning was required.

People who needed support from 2 staff at night were not always supported safely. The provider rostered 1 waking member of staff with support from an on-call arrangement. However, staff told us they frequently supported people to move position at night by themselves rather than wake the on-call staff member. This put people at risk of harm due to poor moving and positioning.

Staff training and competency arrangements did not provide assurance people were supported safely. The provider's training records showed 12 of 15 staff had not completed moving and positioning training in line with the provider’s timeframes, the assistant manager’s training was recorded as out of date in all 19 subjects identified by the provider as mandatory. No face-to-face practical moving and handling training had been completed, and the provider could not produce documented competency assessments. This increased the risk staff might not have the knowledge, skills and competence required to support people safely.

However, staff had been recruited in line with the regulation and the provider's policies.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. During the site visit, toilet paper in the staff toilet was damp and later no toilet paper was available.

Senior staff who had been identified as the infection prevention and control lead had only completed online training.

The provider did not undertake any audits to identify areas of improvement in infection prevention and control. This meant there was a lack of oversight in this area
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Risks associated with prescribed emollients and topical medicines had not been adequately assessed. Two people were prescribed products which had warnings fabrics contaminated by the products could burn more easily, however, the provider had not assessed this risk as no corresponding fire-risk assessments were in place. This meant that the provider failed to take reasonable steps to identify and mitigate these risks.

On person was prescribed a medicine to take each night. No medicine administration record (MAR) was in place. This put the person at risk of not receiving medicines as prescribed. This was not in line with nationally recognise guidance or the providers policies. The provider had failed to identify this in any management review of medicines.