Merrymeet Residential 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 changed to 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 legal regulation in relation to the ways people’s medicines were managed.

This service scored 56 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff were not given effective tools or guidance to carry out their roles. Incidents and accidents were not analysed to help reduce the risk of them happening again. Any lessons learned were not discussed or shared with the staff team to ensure they were aware of any changes and how to mitigate risks. The policies and procedures in place for staff had not been reviewed and were not always the most effective.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

Assessments were undertaken on people’s needs prior to moving into the service, or as soon as possible if people were placed in an emergency. However, we found people’s health conditions were not always included in their initial care planning records. The provider worked with other professionals involved in people’s care to help support them to develop their skills to help them move on to more independent living.

The provider did not always work well with people and healthcare partners to understand what being safe meant and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect.

The accident and incident reporting process was basic; themes and patterns could not be easily identified and acted upon to help prevent repeat incidents. A more robust process was devised and introduced by senior management during this inspection. We saw an incident had occurred that constituted potential emotional abuse; this had been dealt with and resolved by a registered manager. However, we were not assured this had been escalated and reported to the host authority safeguarding team.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Records demonstrated DoLS applications were made but there was no formal process in place to inform the management team when DoLS renewals were required.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

An eating and drinking management plan was in place with acceptance of risk for one person. One of the strategies advised from the hospital consultant and speech and language team (SaLT) member, included supervision of diet and fluids by staff. We noted occasions when food and fluids were given but not observed or supervised by staff whilst the person was eating and drinking. This strategy was not outlined within their care plan, nor was it documented within a risk assessment.

Not all health conditions had been identified or included within another person’s initial care planning documentation. Health conditions such as diabetes and epilepsy were not reflected in the person’s care plan, nor on their medication file. No action had been taken to check on these health conditions whilst the person had been living at the home, although the person had suffered no direct harm.

Risk assessments were not reviewed or updated in a timely manner following identified changes in people’s health. Staff were not provided with information and techniques on how to best manage the risks associated with people’s changing needs and declining health.

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

Health and safety checks had been carried out, and the provider was compliant, for example, regarding fire safety, gas safety and electrical equipment testing. There was a system in place to manage the maintenance of the building; work was ongoing in relation to replacing fire doors to ensure the home remained compliant in the future.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Supervision of staff did not take place regularly. The provider had not always checked staff's competency to ensure they understood and applied best practice. We did not see any evidence staff had been provided with the opportunity for an annual appraisal.

Staff told us they liked working at the service. Staff completed aspects of mandatory training, but the provider did not have good oversight of the training all staff had completed. Staff considered additional training in complex mental health conditions, dementia and substance misuse would be beneficial; we included this in our feedback to the provider.

Safe recruitment processes were followed. Some staff had worked at another home run by the same provider and had transferred to Merrymeet in 2025; some people had also chosen to remain at Merrymeet, so there was continuity in their support. We observed staff being kind and caring and responding to people’s needs when required.

The provider had systems in place to assess and manage the risk of infection. They shared concerns with appropriate agencies promptly.

There were dedicated domestic staff, although some people were reluctant to have their personal spaces cleaned, which was respected. We observed most areas of the home to be clean and tidy. Staff cleaned people's rooms each morning and when required. Staff were provided with appropriate personal protective equipment [PPE]. Shortly after this inspection we contacted a relevant infection control professional; they had identified no concerns during a recent compliance visit.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified issues with the storage and documentation of controlled drugs. A controlled drug had not been booked out of the controlled drugs book but was not stored safely and could not be located by staff. It was later found in the senior carer’s office awaiting disposal; it is not clear if this was being stored as per controlled drugs good practice guidelines.

Other pain relief medication, correctly stored in the cabinet, had not been booked into the home or the controlled drugs book. Records we saw reflected occasions when a person might have benefitted from pain relief, but this had not been offered, potentially because of these errors.

There was insufficient evidence staff had received appropriate medicines training and competency checks to ensure they could administer medicines safely. The registered manager addressed this after the inspection; an overdue check on a staff member’s competency was completed on 14 August 2026.