Marigold 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. This is the first assessment for this service. 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 the legal regulations in relation to safe care and treatment and safeguarding. Safeguarding concerns were not always identified or reported appropriately. Risks relating to people's health and safety were not always effectively assessed and monitored. Improvements were needed to medicines management and environmental safety.

This service scored 53 (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 did not always demonstrate an effective culture of learning from incidents and safety events. We identified incidents involving people living at Marigold House that should have been recognised as safeguarding concerns but had not been escalated appropriately. This reduced opportunities for leaders to identify patterns, investigate concerns and take action to reduce future risks.

In response to our concerns, the provider reviewed incident reporting processes, completed retrospective safeguarding referrals and introduced additional governance arrangements intended to improve incident oversight.

However, where people had experienced accidents such as falls, these had been reviewed by management and actions had been taken to reduce the risk of future occurrences.

People generally had timely access to healthcare services and external professional support when required. Records showed staff sought advice from professionals such as GPs, specialist nurses and other healthcare services where concerns about people's health were identified. Care plans and records demonstrated external professionals were involved in supporting people's health and wellbeing. People and their relatives told us the provider carried out assessments of their needs before they moved to Marigold House.

People were not always protected from abuse and improper treatment. During the assessment we identified several incidents between people using the service which had not been recognised as safeguarding concerns or reported to the local authority safeguarding team. These included incidents where people had experienced physical and verbal aggression and were left distressed or frightened following interactions with another person using the service.

We also identified concerns relating to one person's refusal of essential pressure care support. The provider had not fully considered whether these concerns met the threshold for safeguarding consideration as a potential self-neglect concern. A leader told us this person regularly refused support with repositioning; however, their care plans and care records did not consistently evidence this. This reduced assurance that risks of neglect and avoidable harm were being identified, assessed and managed appropriately.

Following our feedback, the provider reviewed records, submitted safeguarding referrals retrospectively and strengthened oversight arrangements.

Information was displayed throughout the service advising people, staff and visitors how to raise concerns internally and externally. Although they had not always demonstrated this, staff we spoke with understood how to recognise and report safeguarding concerns. People generally told us they felt safe. One person said, “I do feel safe living here. Everyone looks after you and caters for your needs.”
 

The provider did not always ensure risks to people's health, safety and welfare were effectively assessed, planned for and managed. Whilst risk assessments and care plans were in place, they did not always contain accurate or up-to-date information to guide staff in supporting people safely. We identified examples where guidance relating to people's health conditions and emotional wellbeing was not always sufficiently detailed to support consistent care delivery. Records did not consistently demonstrate people had received repositioning support in line with their assessed needs, which reduced assurance that risks relating to skin integrity were being effectively managed.

In response to our concerns, the provider told us they would continue to review care plans and strengthen oversight of repositioning records. We will check for sustained improvement at our next assessment.

However, there were also positive examples of risk management. Risk assessments relating to areas such as mobility and health conditions were in place, and the provider had completed positive risk-taking assessments to support people to make choices and maintain independence in line with their preferences. A person told us, “They make me feel safe.”

The provider did not always identify and mitigate environmental risks effectively. We identified an unsecured oxygen cylinder, used razors located within communal bathrooms and armchairs in need of replacement or deep cleaning to remove staining and maintain cleanliness. This increased risks relating to people's safety and infection prevention and control.

However, safety certificates and servicing records were in place. The provider had systems to monitor environmental safety and took action in response to concerns identified during the assessment.
 

Feedback from people, staff and relatives regarding staffing levels was mixed. While some staff felt staffing levels had improved, others described occasions where people may experience delays, particularly in areas supporting people with higher dependency needs. Some staff told us staffing pressures during busier periods could affect planned care interventions, including supporting people with repositioning needs. A person told us, “Staff appear busy all the time.” A staff member said, “Since having 3 staff things have improved and staff feel better.” During our assessment, there were enough staff available during our assessment to meet people's immediate needs. We observed staff responding to people, providing support and supervision and completing day-to-day care tasks.

Recruitment records demonstrated appropriate pre-employment checks had been completed and staff described receiving induction, training and supervision. However, improvements were required to workforce oversight. We identified significant levels of overdue mandatory training and the provider acknowledged previous arrangements for monitoring and escalating non-compliance had not always been applied consistently. This reduced assurance that all staff had always received the training and support necessary to safely meet people's needs.

In response to our concerns, the provider reviewed staff training compliance, strengthened escalation arrangements for overdue training and told us they would continue to improve oversight of staff competency and supervision.

Overall, the provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies where required. Infection prevention and control audits were in place and actions had been taken where areas for improvement had been identified. Staff had access to personal protective equipment and previous audits found the home to be generally clean, with appropriate hand hygiene and waste management arrangements in place.

The provider did not always make sure medicines and treatments were managed safely. We identified medicines overstocking, prescribed nutritional supplements without dispensing labels attached and concerns relating to insulin storage and temperature monitoring. This increased the risk of medicines not being stored and managed safely.

In response to our concerns, the provider introduced a locked medicines box, commenced daily temperature monitoring and worked with pharmacy services to review medicines storage and stock management arrangements. Excess medicines were arranged to be returned to the pharmacy and medicines ordering arrangements were reviewed. We will check for sustained improvement at our next assessment.

However, people told us they generally received their medicines as expected and there were no reported concerns regarding access to prescribed medicines. A person told us, “The system is set up very well for me.”