The Marbrook Centre

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 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 the legal regulation in relation to safeguarding. When potential safeguarding incidents happened on one floor of the service supporting people living with dementia, these were not always being reported so they could be investigated. This limited the opportunity to learn lessons and put measure in place to mitigate risks and improve safety for people.

This service scored 59 (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.However, they did not always identify concerns about safety consistently in all areas of the service.Staff were not always reporting incidents so they could be investigated to see if lessons could be learned and shared to improve people’s support.

However, there were opportunities where a learning culture was promoted at the service such as staff handovers and meetings.The management team had daily meetings to review incidents that staff had reported.One person said, ‘‘[Staff] are very quick to change things to make sure I am as independent as I can be.’’ A relative told us, ‘‘[Staff] are good when [family member] has a fall. They have put more 1:1 measures in place as a result and they have had less falls now.’’

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 using the rehabilitation floor of the service were supported to use the service for a short period of time and safely go back to their homes afterwards. People had access to professionals such as physiotherapists at the service and staff also supported people to access external health professionals when this was needed. One person said, ‘‘I think the staff are brilliant and the help they have given me means my legs are better now and I will safely be going home soon.’’ A professional working at the service told us, ‘‘[Staff] always make sure they follow our treatment plans we put in place for people. We all work together as one big team.’’

People were not always protected from abuse and improper treatment.Staff were not reporting incidents which were potential safeguarding concerns on one floor of the service which supported people living with dementia. For example,when people were physically or verbally abusive toward each other or when people were asked to stay in certain areas of the service when they were feeling anxious, leading to a restriction on their freedoms.This had the potential to have a significant impact on people who were unable to speak up about the potential abuse they were experiencing as incidents were not being identified or investigated to see if there were safer and better ways to support people.The registered manager and management team took immediate action to make sure staff now reported these concerns and also retrospectively reviewed incidents which had not been appropriately reported to put measures in place to improve safety. However, this was as a result of the findings of our inspection and not due to the service identifying and taking action independently.

The issue on the floor of the service supporting people living with dementia was not prevalent on the other two floors of the service which supported people living with physical disabilities and people who used the service as a rehabilitation service to regain their skills and independence. When identified, safeguarding concerns were taken seriously and investigated. The management team reported concerns to the safeguarding team where necessary and reviewed outcomes to see if lessons could be learned.One person said, ‘‘I feel safe here and it is like a second home for me.’’ A relative told us, ‘‘[Family member] is safe there and staff always let me know if something happens like a fall.’’

The provider worked well with people to understand and manage risks. Staff provided care that enabled people to do the things that mattered to them.Risk assessments and care plans were detailed and gave good guidance about how to support people to take risks safely. Staff knew how to keep people safe and risk assessments and care plans were focused on helping people improve their health and independence. We observed staff supporting people to use equipment such as hoists safely.People and their relatives were asked to discuss care plans and risk assessments on a regular basis.A person told us, ‘‘I have [piece of equipment] to use now as my [health need] has changed. But staff have a care plan to get me back to not needing it soon.’’ A relative told us, ‘‘I am very happy with the care and I know [family member] has all the equipment they need to keep safe.’’

The provider detected and managed all potential risks in the care environment.The environment was safe. Staff kept equipment people used safe and in good working order and carried out checks of the building to help make sure it was safe. Fire safety risks were understood by staff and well managed. One person said, ‘‘I cannot complain about the look of the service.It is like a home,but you also have all the equipment you need. We have fire evacuation practices too.’’

The provider did not always make sure staff deployment was effective.There were several times of day where people went for extended periods of time without meaningful engagement from staff. Whilst staff understood processes to safeguard people from abuse, they were not consistently following these by reporting safeguarding concerns. Some staff members training and competency was not being effectively overseen making it unclear how the management team were assured staff were competent in their job roles. The registered manager and management team took action, in response to our feedback, to improve staff safeguarding competence by completing supervisions and also started to review staff deployment throughout the day to see where this could be improved.

However, there were enough staff to support people with their needs such as personal care and eating and drinking and people and relative feedback confirmed this. Staff told us there were enough staff to support people safely, though they would sometimes like more time to spend speaking with people.Staff were knowledgeable about most areas they had training in such as moving and handling and supporting people to eat and drink. The provider recruited potential new staff safely in line with legislation. One person said, ‘‘Staff come within minutes if you need anything. They are all well trained and confident.The night staff talk with the day staff,so they are all on the same page.’’ A relative told us,‘‘There are always staff about when we visit [family member] and I am confident all their needs are met.’’

The provider assessed and managed the risk of infection.Staff were trained in IPC and told us they had the necessary equipment to keep the service clean. We observed the service to be visibly clean.Staff whose role was to keep the service clean took pride in their work and knew how important it was for people’s home to be kept clean.Audits and checks were in place to monitor the cleanliness of the service and the effectiveness of the IPC measures in place. A person told us,‘‘The staff make sure the service is kept clean and they even clean the equipment I use on a daily basis.’’

The provider did not always make sure that medicines and treatments were safe and met people’s needs,capacities,and preferences.Care plans and protocols for medicines people took ‘as and when required’(PRN) were not always detailed enough for staff to know when to administer these medicines.One person had been supported to have a PRN medicine administered on a daily basis for a long period of time, however this had not been noticed or actioned by the staff team to see if the medicine was still effective. One person’s medicines were not being stored at the correct temperature but had been administered multiple times.The registered manager addressed these issues during the inspection.

Other areas of medicines administration were safe. People received their medicines on time and staff knew how people liked to be supported. Staff were trained to administer medicines and had their competency to do so checked regularly.One relative told us, ‘‘I can trust staff to administer [family members] medicines safely.’’