Maryland Care 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.

This is the first assessment for this service registered on 15 December 2021. This key question has been rated 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 and the way people’s medicines were managed.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although any accidents and incidents were identified and recorded by staff, there was no analysis of them to help identify any trends/patterns. Accident and incident forms had not been signed by the registered manager to confirm they had been reviewed. Therefore, we could not be assured any reviews or investigations were sufficient. This meant opportunities were missed to implement measures to help prevent recurrence.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Some people’s care plans we looked at were incomplete, there was a risk people may not receive the care and support they needed as this information had not been captured in people’s plans of care. For example, one person’s pre-admission information from an external partner specified the person had a specific risk related to a health need. Despite this information, the provider had failed to implement the necessary care plan and risk assessment in place to help manage this need effectively.

Although we were assured the provider concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, the provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

A safeguarding policy was in place to help guide staff on how to recognise and react to any potential safeguarding incident. However, the policy was outdated and had not been reviewed as often as it should. For example, it did not record all the various types of abuse people could be exposed to. Although staff told us they wouldn’t hesitate to report and act on any concerns, they were unsure of where to take any concerns outside of the service.

We asked for sight of a whistleblowing policy however, this could not be located by the registered manager. This meant we could not be fully assured staff had the appropriate guidance in relation to raising any information of concern in a confidential manner.

People and their relatives told us they felt safe living at the home. One person told us, “I feel settled. I feel safe.” Comments from relatives included, “Mum is safe, and my mind is at rest finally” and “Yes, I do feel [Name] is kept safe here.”

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.

People’s risk assessments and care plans lacked adequate details of people’s individual needs and the care they required. Some risks in relation people’s care had not been assessed at all, despite some people having been identified at high and medium risk of harm from risks relating to weight loss, falls, pressure wounds and infection. This meant staff lacked guidance on how to prevent this risk from occurring.

For example, for 1 person undergoing therapy which caused a risk to the general environment, risk prevention measures had not been put in place to help ensure the safety of the person and the environment was properly protected. Another person had a medical condition which placed them at risk of infection. The symptoms to spot and the action to take in the event of an infection had not been assessed. This meant staff had no suitable guidance how to prevent and support the person if and when an infection occurred.

As risk assessments had not always been carried out for people, we could not be assured risk management considered the least restrictive option, which may have limited people’s control over their independence.

We found some personal emergency evacuation plans (PEEPS) for people lacked important information, such as the number of staff required to assist the person and the nearest place of safety. PEEPS provide emergency service personnel with summary information about a person’s needs and risks during an emergency situation such as a fire.

This was a breach of Regulation 12 as there was no suitable system in place to ensure that identified risks in relation to people’s care were adequately identified and managed.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Safety checks of the environment were not always carried out. The provider was not always carrying out and properly recording checks of the premises and equipment. For example, water temperature testing and window restrictor checks. This meant people were potentially at risk of scalding or falling from height.

Many external contractor checks were out of date. For example, PAT testing (portable appliance testing), Legionella checks and servicing checks of equipment such as the bath hoist.

Fire risk assessments and fire safety checks were not being completed. Practice fire drills involving staff were not being completed as often as they should. We observed the fire safety guard on some people’s bedrooms doors were broken and doors were being propped open with objects, so they would not close automatically in the event of a fire.

We observed a storeroom on the ground floor which contained cleaning products was unlocked which was accessible to people. Personal toiletries were found in the communal shower room. This meant people were at risk of avoidable harm from factors within the environment.

This was a breach of Regulation 12 as there was no suitable system in place to ensure any potential risks in the environment were adequately identified and managed.

We raised our concerns with the registered manager who acted on our findings immediately and arranged for the completion of checks such as PATs, Legionella and fire by the end of the inspection process. They told us the safety of the people would be made a priority.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Although we received positive feedback from people and their relatives about how well staff cared for people, we could not be fully assured staff were trained. We requested a staff training record to ascertain which staff had received training and in what topics, however, the registered manager was not able to provide us with this.

Similarly, there was no evidence of staff having undergone any supervision or appraisal processes. This was important because staff supervision was a process where a manager provides support, guidance, and feedback to an employee to help with their professional development and address immediate concerns and training needs.

However, staff told us they had received a good induction and had received training including fire training. Comments from staff included, “The manager gave me a good induction, and I have completed all my training” and “My induction was positive, the manager showed me around and did fire checks and I shadowed the manager.”

Some people felt at times staff could be, “Stretched” whilst others felt “There was enough staff.” One person commented, “There’s possibly not enough staff at some times of the day, but if I ring my bell, they come quick.” People told us they thought staff were well trained, one person told us, “They [staff] know what they are doing.”

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.

We could not be fully assured the risk of infection was monitored as effectively as it should be. Checks and audits were not always completed by the provider. Although the domestic staff kept cleaning records, these were handwritten and difficult to follow and did not encompass all areas where cleaning should be performed daily, for example, in sluices. This meant there was no adequate system in place to help prevent the build-up of dirt and bacteria in higher risk areas of the home.

Whilst the environment was largely clean and well maintained, we did note dusty window ledges in one of the communal lounges, an unclean coffee table and a warped bathroom cabinet in the main bathroom, which meant effective cleaning was compromised.

However, there were adequate supplies of personal and protective equipment such as aprons, gloves and anti-bacterial hand gels available in the home.

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.

People’s medicines were not always managed effectively. The temperature of the room where medicines were kept was not always being recorded. As the temperature of the room exceeded the optimum temperature for which medicines should be kept, this meant their effectiveness was compromised.

For people who were prescribed PRN (when required) medicines, PRN protocols were not always in place. This was important as protocols provide guidance for staff on how and when to use such medicines and can help prevent people from being given medicines unnecessarily.

For people who were prescribed topical medicines (such as creams and ointments to the skin), medicine records did not contain any guidance for staff on which part of the body to apply them, meaning there was a risk of topical medicines being applied inappropriately.

Some people were prescribed thickening powders so drinks could be served at a safe consistency to lessen the risk of choking and aspiration. However, staff were not recording when this was being administered in people’s drinks. This was important as in the event of a choking incident, there would not be a reliable record the person had received their drink as prescribed by the dietician.

For 1 person who was prescribed pain killers, we saw how they were being given this medicine before the minimum time between doses had passed, meaning the person was at risk of being overdosed.

We checked a sample of people's medication administration records (MARs) and found some people's were inaccurate and their stock of medication did not balance with what had been administered. This indicated people may not have received the medication they required.

For people with medicines recorded on handwritten MARs, important details such as the quantity of tablets which had been received into the home was not recorded. The records had not been signed and dated as per best practice NICE guidelines, (which are evidence based recommendations for health and social care). It was important to check the accuracy before the MAR was used. 

This was a breach of Regulation 12 as there was no suitable or reliable system in place to ensure medicines were managed safely.