Marnel Lodge 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Staff knew what incidents to report and how to report them. The registered manager shared learning with staff through team meetings, supervision and staff communication channels.

The registered manager told us they received safety alerts from the government, local authority and CQC which informed them of upcoming risks along with themes and trends to ensure they could take appropriate action to mitigate these risks.

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. People had initial assessments in place that covered all appropriate areas.

The provider had a robust admissions policy in place. The registered manager described how they assessed people to establish suitability and compatibility prior to moving in. Processes were in place to support people to view their new accommodation. There was a transition period to help people settle into their home. A relative told us, “The move from hospital to here was fantastic, they [registered manager and staff] were instrumental in the successful transition.”

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 consistently told us they felt safe living in the home and staff knew how to protect people from abuse and who they would report any concerns to both internally and externally. The registered manager shared concerns appropriately by following the correct reporting process and informing all relevant agencies.

Where restrictive practices were in place, they were kept to a minimum. Where required, Deprivation of Liberty Safeguards (DoLS) were in place to legally authorise restrictions placed on people to keep them safe.

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.

Staff knew people very well and understood how to keep people safe when providing care. People told us they were involved in developing their risk assessments. People were supported to manage risk while maintaining independence and the service promoted positive risk-taking. For example, people were assessed for risks of choking and risks relating to medical conditions.

The registered manager described situations where they had collaborated with people, their relatives and healthcare professionals to ensure least-restrictive actions were taken to support people safely. A staff member told us, “Risk assessments are person centred, proportionate and reviewed regularly.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Relatives told us people had access to specialist equipment such as walking frames, wheelchairs and hoists. Records showed equipment in place had been assessed and maintained to ensure people’s safety. A staff member told us, “I remain vigilant and report any hazards, faulty equipment, or maintenance concerns as soon as they are identified.”

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 used a dependency tool to determine the safe staffing levels required to support people safely. Feedback from people and their relatives was mixed. Some people told us there were fewer staff at weekends. However, staff rotas showed there were enough staff to meet people’s needs, and we observed sufficient staff throughout the inspection.

The provider ensured staff received support, supervision and development. Most staff had completed statutory and mandatory training and competency assessments. Staff supervisions were mostly taking place in line with the provider’s policy.

Recruitment was carried out safely. The provider completed all appropriate pre-employment checks before staff began work, including checks of identity, employment history, references and Disclosure and Barring Service (DBS) status.

The provider 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 had an up-to-date Infection Prevention and Control (IPC) policy. Staff attended IPC training. We reviewed cleaning schedules which were consistently completed. People and their relatives told us the home was clean, and we observed this. Staff had access to Personal Protective Equipment (PPE), and we observed PPE being used appropriately throughout the inspection.

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.

Staff received medicines training, and their competency was checked to ensure they understood the requirements for the safe administration of medicines. Staff supported and involved people to manage their medicines and followed best practice guidance for administering medicines. The staff team were proactive in reporting any changes to people’s medicines promptly.

People received their medicines as prescribed. One ‘when required’ medicines protocol was missing, and some protocols did not include sufficient information to guide staff on how to administer these medicines. For example, where medicines had variable doses, it was not clear what dose people should receive. We spoke with the registered manager and senior leaders about this. They responded immediately by implementing the missing protocol and updating the others. Staff knew people well and confidently described how they would manage ‘when required’ medicines.