Martlet Manor

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 changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

The service ensured incidents and concerns were immediately investigated and changes made to people’s care and support where required.

Staff were involved in discussions about safe practice through supervisions, team meetings and other regular contact with their manager to ensure lessons were learned. Daily meetings were held with managers and senior staff on shift to discuss changes in people’s needs and agree actions to address these where required. Staff told us they received the information they required in a timely manner when there was any change in a person’s care and support needs.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

Processes to support safe care delivery were largely effective. The provider liaised with other services, and people’s family members where appropriate, when they were moving to and from the home. Risk assessments contained clear guidance for staff to ensure care was carried out safely. Information and guidance provided by healthcare and other professionals was included in people’s care plans and staff demonstrated they were aware of how to follow any such guidance.

People told us they felt safe living at the home.

People and their families were provided with information about safeguarding and knew how to raise any concerns they might have. We observed a resident’s meeting where safeguarding was discussed in ways they understood.

Staff had received safeguarding training. They understood their roles and responsibilities in ensuring people were safe and reporting any incidents or suspicions immediately.

Safeguarding concerns had been reported appropriately to the local authority and notified to the CQC as required. The provider monitored all safeguarding concerns and had taken appropriate action to keep people safe as required.

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

Staff worked with people, and their family members where appropriate, to develop and agree risk assessments. People's care plans contained clear, specific safety management plans that enabled people to do the things they wished to do with minimal negative outcomes.

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 home’s environment was clean and free from odour. The design of corridors, communal areas, bedrooms and bathrooms was accessible for people with a wide range of physical, sensory and other needs. The provider had carried out risk assessments relating to the environment and use of equipment.

However, we found concerns about safe storage of equipment and cleaning materials. Although these were generally well stored, a shed in the garden was unlocked and a member of staff had left the key to a trolley containing cleaning materials unattended when they were dealing with something else. We raised this with the registered manager who dealt with these issues promptly. During our inspection we saw a large padlock had been used to secure the garden shed and a new keyring system for cleaning trolleys had been put in place to ensure housekeeping staff kept the keys to locked trolleys on their persons at all times.

Regular safety checks were carried out and external checks on, for example, gas and electrical equipment had taken place. Fire safety checks were carried out and staff had received training on what to do in case of fire or other evacuation of the service. The provider had emergency evacuation procedures in place should this be required.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider ensured staff were recruited safely. Satisfactory references and criminal records checks were sought prior to recruitment to any roles at the home.

All new staff received a detailed induction at the commencement of employment. This was linked to the Care Certificate which provides a set of learning competencies for staff working in health and social care services and was signed off by a manager when completed satisfactorily. All staff received regular refresher training in a wide range of mandatory courses dependent on their roles at the home.

Staff members received regular supervision sessions with a manager to support their development. They also participated in team meetings where there was general discussion about a wide range of care and practice issues, Staff told us these were helpful. A staff member told us, “I don’t have to wait for a meeting if I want to discuss anything. I can talk to my manager at any time.”

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The provider ensured infection control was safely managed, and risk assessments included clear instructions for maintaining hygiene and safe infection prevention and control. Staff received training in infection prevention and control. Staff wore personal protective equipment, such as disposable masks, gloves and aprons. These were disposed of correctly along with other clinical waste.

Domestic staff were observed cleaning throughout the days of our inspection. The environment was seen to be clean and tidy throughout. We observed kitchen staff preparing food and saw they cleaned surfaces immediately after use. Food was stored hygienically and safely and was within date.

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

Staff had received training in safe administration of medicine. Staff administering medicines knew what people’s medicines were and why they were prescribed. We observed medicines administration rounds and noted staff gave people their medicines discreetly. They explained the medicines to people and offered a drink of their choice with which to take them.

Medicines were stored safely in locked clinical rooms. Where appropriate medicines were stored in refrigerators. Clinical room and refrigerator temperatures were taken daily. Staff used trolleys on medicines rounds and we observed these were locked as soon as any medicine had been removed from them.

Medicines records were up to date and correct. The home used an electronic medicines administration record (EMAR) system. This alerted staff when medicines had not been recorded as received at the correct times. Protocols for PRN (as required) medicines were in place. Stock counts of medicines were correct. The deputy manager had carried out regular audits of medicines.