Merlin Manor Care Centre

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 the last inspection we rated this key question requires improvement. At this inspection 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.

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 management team had a proactive and positive culture of safety, based on openness and complete honesty. Systems were in place to record and review accidents and incidents, and lessons learnt were shared with staff to improve practice. Overall, staff described opportunities for reflection and learning from events, and governance processes included regular discussion of safeguarding and incidents. Where things went wrong, there was evidence the service reflected on practice and made improvements to keep people safe. One staff member said, “I know how to raise concerns within the workplace. However, I have trust not only would they be taken seriously, but investigated appropriately, and feedback on the outcome would be given.”

Systems were in place to ensure safe care pathways and transitions. People’s needs were assessed before admission and reviewed when circumstances changed. Information was shared appropriately with other professionals to support continuity of care, including during transfers and transitions. These systems helped reduce risks and ensured people received coordinated and timely support. However, inconsistent staffing levels impacted continuity and the ability to support people safely during transitions between services or within the home. Professionals reported difficulty contacting the service and locating staff on units, which could delay information sharing and coordinated care. Staff also described limited time to review care plans, stating they often “just learn as we go along,” which created risks where people’s needs changed or when new staff supported them. Relatives reported staffing constraints led to them having to repeatedly chase for updates. These issues increased the risk of gaps in care planning, communication and oversight during key transition points.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. In general, they understood safeguarding procedures and described concerns being acted on appropriately and within expected timescales. Some people could become distressed and would attempt to assault or engage in a negative way with others. Most staff had not received any training around how to manage these situations, and their lack of knowledge could lead to them or others being injured or overly restricted. The registered manager and clinical team were aware of this shortfall and had raised this with the provider but as yet this had not been addressed. Staff understood when Deprivation of Liberty Safeguards (DoLS) authorisations would need to be sought, the impact of the recent Supreme Court judgement and what to do if there were conditions imposed.

People were supported to be involved in managing risks, and care plans and risk assessments were generally in place and reviewed. Staff understood people’s needs and aimed to balance safety and independence. However, risk assessments did not always clearly detail actions to mitigate risks, and some were not sufficiently personalised. The staffing pressures lead to people and relatives not being consistently involved in risk management or being kept informed of incidents. A relative said, “There aren’t enough staff on this floor, but I don’t know about the other units. However, the staff work incredibly hard despite the shortages. I can’t fault the respect and dignity but sharing information with us can be a little slow.”

The provider maintained a safe environment that reduced risks to people. Health and safety checks were carried out, and environmental risks were identified and managed. Equipment was maintained and used safely. These arrangements helped ensure people could move around the service safely and receive care in an environment that supported their wellbeing.

The provider had not always made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Recruitment practices and training levels met the required standards. At the last inspection we found there was a breach of regulation related to staffing. The previous regional managers worked with the team to ensure this was addressed.

Over recent months the staffing levels have decreased. Feedback from people, relatives, professionals and staff consistently highlighted there has not been enough staff, particularly at night, which impacted timely care and response times. Staffing levels did not always reflect people’s complexity or dependency, which placed people at increased risk. Staff described working under pressure, with delays in completing care tasks and increased risk when managing complex needs. Inspection observations confirmed these concerns. There were delays in responding to people, limited staff visibility and delays during mealtimes. Staff reported they had little time to review care plans and often relied on experience rather than documentation. A visiting professional said, “I have noted on a few occasions during visits that there is limited staff available on some units. On the ground floor you appear to notice staff presence, however on floors 1 2, I have noticed that there have been quite a few occasions in which I find it very difficult to locate staff.”

Staff assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff appropriately followed the required infection control guidelines. They supported people to adopt good hygiene practices.

The provider did not always ensure the safe and effective management of medicines. Medicine records were not always clear and the care plans needed further information or updating when changes occurred. Records of regular medicines followed national guidance including recording people’s allergies. However, where stock was adjusted in the electronic medicine record this was not escalated for investigation. Some medicines were out of stock and could not be given. Antibiotics for 1 person was given at an incorrect dose. This meant we could not be assured medicines were administered as prescribed.

Some people were prescribed medicines to be taken on a ‘when required’ basis or with a variable dose. Guidance for how these medicines should be administered needed to include more person-centred information, specific variable dose directions and be linked if more than one medicine for a condition. Records needed to show why medicine was given and whether effective. For creams applied by care staff as part of personal care; some guidance was missing, and records were not fully completed. Patch application records were not fully completed to show rotation in line with manufacturers guidance.

Audits had picked up some of the issues we found. The staff team had begun to take action to resolve these matters.