Marner House

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 good. At this inspection the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a positive learning culture within the home where people and staff were supported to learn from mistakes and improve practice. Staff told us they felt confident to acknowledge and report errors, incidents and accidents without fear of blame. They said they were encouraged by leaders to reflect on what had happened and use learning to improve outcomes for people.

The registered manager demonstrated a commitment to continuous improvement and used lessons learned to strengthen the service provided. For example, following discrepancies identified during previous medication audits, they had implemented a more robust system to reduce the risk of a reoccurrence, and improve oversight. Staff told us they valued this process change because it further increased their confidence.

Staff felt able to raise concerns and share feedback with managers and told us their views were listened to and acted upon. Learning opportunities were routinely embedded into team meetings, where staff discussed scenarios and reflected on how they would respond to different situations. This helped staff develop their knowledge, and decision-making skills.

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 provider worked collaboratively with people, their families and relevant professionals to ensure admissions and discharges were carefully considered and well managed. For example, the registered manager described how 1 person was supported to transition into the home gradually, increasing the length and frequency of visits over several weeks. This helped them become familiar with their new environment and build relationships with staff prior to admission.

Staff received detailed information about people before they moved into the home, enabling them to prepare appropriately. One member of staff told us, "When we have a new service user the management tell us about them before they come so we know what support they need and equipment they may use, things like that. We are always prepared to welcome new service users and start helping them as soon as they arrive.”

Communication between the management and staff team with partner organisations was positive. A healthcare professional told us, "Communication is very effective. We regularly meet and review care." Care plans were kept up to date, and relevant information was shared appropriately with professionals to ensure continuity and consistency of care.

People were supported to access healthcare services when required. Staff supported people to attend routine healthcare appointments and accompanied them to hospital during emergencies. Where people were admitted to hospital, staff visited them regularly to help ensure their needs, preferences and routines were understood and maintained.

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.

People felt safe living at Marner House and knew who to speak to if they had any concerns. One person told us, “I feel safer here than any of the other places I have been, and I have been to quite a few. I think it’s the staff and the other people.”

Staff demonstrated a clear understanding of how to keep people safe and were confident in recognising and reporting concerns. They could describe different types of abuse, and understood the actions required to protect people from harm. One staff member told us,: “I did my safeguarding training and we do refreshers. You learn about the different abuses, physical, financial, neglect. If I suspected something, I would speak to the service user to make sure they were safe and then I would escalate it to the manager or deputy. If they weren’t available, I could contact the safeguarding team. The number is in the office.”

The registered manager understood their responsibilities in relation to safeguarding. They were aware of the processes for investigating concerns and reporting safeguarding incidents to the local authority and to us (CQC).

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called The Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home. Where people had restrictions placed on their liberty, this was detailed in their care plan. For example, where a person had been assessed as lacking capacity to consent to care, the provider had ensured DoLS applications had been submitted to the relevant supervisory body.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were supported to take positive risks. They were actively involved in discussions about their care, support and the management of potential risks. One person told us, “They talk to me and make suggestions about how we can do things and ways I can deal with things.”

We saw examples of people being supported to achieve greater independence through accessing the local community, managing their own finances or medicines, and progressing to the service’s step-down flats. Staff balanced safety with people’s rights to make choices and develop skills, helping them to work towards their personal goals.

Care plans and risk assessments were personalised and clearly identified individual risks, alongside guidance for staff on how these could be safely managed and mitigated. Records showed risk assessments were regularly reviewed and updated to reflect people’s changing needs and progress. For example, mobility risks were reassessed as people became more independent through rehabilitation, and care plans were amended to reflect new abilities, goals and support requirements.
 

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.

Marner House comprises of a main house and 2 separate off-site residential buildings, each containing 2 self-contained flats. Although systems were in place to monitor environmental safety, these were not consistently applied across all parts of the service and were not always effective in identifying risks and ensuring timely action was taken to mitigate known risks. An external fire risk assessment undertaken in January 2026 identified a fire safety concern in an occupied flat and specified a 0 to 3 month timescale for remedial action. We found this action remained outstanding and presented an ongoing fire safety risk. Following our inspection, we received confirmation the required action had been taken.

People regularly took part in fire drills to ensure they knew what action to take in the event of a fire. Staff had received fire safety training and demonstrated an understanding of the actions required to keep people safe in the event of an emergency. Up to date Personal Emergency Evacuation Plans (PEEPs) provided staff with information about how to support people safely during an evacuation. However, we found some staff had difficulty locating this information quickly on handheld electronic devices, which could delay access to important information. This was particularly important as staff would need to rely on support from other services, in the event of an emergency at night time.

We requested the local fire service carry out an inspection of the properties. They provided assurances that all other identified fire risks were being appropriately managed and that arrangements were in place to support people to evacuate safely in the event of a fire.

There were regular checks and audits in place to identify maintenance issues and areas requiring improvement. While these processes were generally effective, we identified some environmental risks which had not been addressed through routine monitoring. For example, a sign said knives should be locked away and they were not, and some routine maintenance jobs had not been completed. The registered manager responded quickly to our findings and took immediate action to reduce these risks.

Regular servicing and safety checks relating to gas, electricity, water systems and equipment were completed in line with the provider's policies and relevant requirements.

Staff understood their responsibilities for maintaining a safe environment and knew how to report and escalate concerns. Staff felt confident issues would be acted upon by management when raised.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff to meet people’s needs.

Night-time staffing arrangements did not provide assurance enough staff would be available to safely support people living in both the main building and the step-down flats, in the event of an emergency. At the time of the inspection the registered manager was unable to demonstrate staffing deployments consistently ensured people's safety in all circumstances. The registered manager told us emergency support would be provided by staff from a nearby service. However, we were concerned these staff may not have the knowledge, training, or understanding of people’s complex needs to safely respond.

Staffing levels during the day were sufficient to support people with their care, individual rehabilitation programme, routines and personal goals. Staffing arrangements promoted continuity of care. The registered manager used a rota system which matched people with staff they knew well and with whom they had established positive relationships.

People spoke positively about the staff who supported them and described having developed meaningful and trusting relationships. One person told us: “The staff are lovely. They are always there. You can go to any member of staff, with anything, and they will make the time to listen, really listen. You sense they are genuine and want to help.”

Staff demonstrated a good understanding of people’s choices and provided consistent support that promoted independence and wellbeing.

Staff were recruited safely in line with the provider’s policy and procedure. Staff received an induction, the training and ongoing support they needed to carry out their roles. The registered manager had adapted the induction process to ensure new staff spent time getting to know and understand people’s needs and completing specialist acquired brain injury training before taking responsibility for delivering direct care and support. Staff shared how this training had improved their understanding of people’s needs and helped them tailor the support they provided.

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.

The provider’s systems and process were not always effective in identifying and addressing potential infection prevention and control risks. We found variances in standards across different areas of the service. Some areas were clean and well maintained, others for example, people’s individual kitchenettes and bathrooms needed more thorough cleaning. This meant the provider could not be assured the risk of infection was always minimised. Some action was taken to address the concerns during the inspection.

Staff did not always follow required infection prevention and control practices. For example, omissions were found in cleaning records and fridge temperature monitoring records. When we shared our observation with the deputy manager they said, “We need to up our spot checks and get them recorded.”

All staff had completed IPC training and understood their responsibilities in this area. The provider did not employ dedicated domestic staff. Instead, people were encouraged to complete domestic tasks independently where this formed part of their rehabilitation goals, with other cleaning tasks undertaken by care staff. One staff member told us, “Sometimes there isn’t enough time to do the cleaning but if we can’t get it done, we pass it over to the next shift.”

Infection prevention and control checks were undertaken as part of the provider’s environmental audits. Audits had identified some of the shortfalls we found and action to address these was planned. However, the audits did not cover all aspects of infection prevention and control practice. This limited the provider’s ability to ensure effective oversight and timely improvement of IPC practices.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored, managed and administered in line with the provider’s policy and procedure and best practice guidance. When medicines were given on an ‘as required’ basis, records were maintained of why they had been given and their effectiveness monitored.

People received their medicines from trained staff whose competency to continue to follow safe medicine practices was regularly reviewed.

Medicines audits and checks were regularly completed. This ensured timely action was taken to address any shortfalls and enabled opportunities for learning and continuous improvement to be recognised and acted upon. Robust systems had been implemented to improve accuracy in administration, and the deputy manager had increased their own checks to assure themselves of compliance.