Maranello Also known as Zero Three Care Homes LLP

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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to; Safe care and treatment, Safeguarding and Staffing. Enough improvements had been made at this assessment and the service was no longer in breach of these regulations
 

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 developed a proactive and positive culture of safety based on openness, honesty and continuous learning. Staff listened to concerns about safety, investigated incidents and reported safety events appropriately. Lessons learned were used to identify areas for improvement and embed good practice.

At the previous inspection, the provider had not consistently reviewed incidents, shared learning or embedded improvements across the service, resulting in repeated concerns and restrictive practices. Since then, leaders had strengthened the service's learning culture. Incidents, safeguarding concerns and behavioural events were reviewed through debriefs, supervision, team meetings and regular Positive Behaviour Support (PBS) cascade meetings, where staff reflected on events, identified themes and agreed actions to improve outcomes.

The deputy manager told us, “Whenever there is an incident, we facilitate debriefing for staff," and the PBS lead described meetings which focused on what was working well alongside areas for improvement and actions to improve people's quality of life. One staff member explained how lessons were learned, stating, “We use team meetings, supervisions, training, updated care plans, clinical cascades, incident and audit reports, and reflective reports to make sure mistakes are not repeated so staff can learn and improve practice.” Staff also told us, “A lot has changed" and described improvements in communication, teamwork and support.

New audit systems, quality reviews and governance processes helped ensure improvements were monitored and embedded into practice. We saw evidence that learning had led to improvements in care planning, risk management, staff competency, the reduction of restrictive practices and the overall quality of support people received. This demonstrated a culture of reflection, learning and continuous improvement which was contributing to better outcomes for people living at the service.

The provider worked effectively with people, families and partner agencies to establish and maintain safe systems of care. Care plans, risk assessments and health information were regularly reviewed to ensure staff had up-to-date guidance to meet people's needs safely.

People's health needs were monitored and they were supported to access healthcare professionals when required. The provider had also strengthened arrangements for planned transitions.
We saw evidence of a structured, person-centred transition process which involved the person, their family and relevant professionals, with information sharing, staff preparation and ongoing support to help ensure safe and successful moves between services. Staff understood people's support needs and demonstrated they worked collaboratively to promote continuity, safety and positive outcomes for people.
 

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.

At the previous inspection, people were not always protected from safeguarding risks, restrictive practices were not effectively reviewed, and people and relatives gave mixed feedback about safety. During this assessment, we found significant improvements. Restrictive practices had been reviewed and reduced, people had greater freedom within their home, and support was delivered in a way that promoted safety alongside people's rights and independence. Relatives and people spoke positively about the service, with people telling us they felt safe and relatives describing increased confidence in the management team and the care provided.

Staff demonstrated a clear understanding of safeguarding responsibilities and knew how to raise concerns both internally and externally. One staff member told us they would report concerns to managers and use whistleblowing processes if needed, whilst another said, "I would go to CQC or the police if I were worried."

The deputy manager had provided training and support to staff in proactive de-escalation strategies, helping staff understand people's behaviours, reduce the need for restrictive interventions and promote least restrictive practice. Staff told us they felt better equipped to support people safely and records showed safeguarding concerns, incidents and behavioural events were reviewed to promote learning and prevent reoccurrence. This helped ensure people were protected from abuse, neglect and avoidable harm.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). At the time of inspection, where appropriate, people had authorisations in place and any conditions in place as part of the authorisation were met.
 

The provider worked with people to understand and manage risks holistically. Staff provided safe, supportive care that enabled people to do the things that mattered to them.

At the previous inspection, people were not always involved in managing risks and staff did not consistently follow risk assessments or support people to achieve their goals. During this assessment, we found significant improvements. Risk assessments and support plans had been reviewed and updated to reflect people's current needs whilst promoting choice, independence and positive risk-taking.

Staff demonstrated a good understanding of people's health risks and the measures required to keep them safe. For example, staff were able to clearly explain how they would respond if a person experienced a seizure, including following their epilepsy care plan and seeking emergency assistance when required.

Staff also understood the importance of balancing safety with people's rights and individuality. One staff member described how a person had previously stopped using public transport, but with planning and support had been enabled to access the bus again safely, commenting, "It was a positive risk to take and it went really well." Staff explained they developed contingency plans and regularly reviewed risks to enable people to access their local community, holidays, activities and new opportunities safely. We also saw examples of people being supported to achieve personal goals, including planned transitions to more independent settings and increased community participation.

These improvements demonstrated people were supported to manage risks in a way that promoted independence, choice and quality of life.
 

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

At the previous inspection, environmental risks were not always identified or addressed, with concerns relating to fire safety, maintenance and the suitability of the home environment. During this assessment, we found significant improvements. The environment was clean, well maintained and designed to meet people's needs. Fire safety actions had been completed, regular environmental checks were in place and maintenance issues were addressed promptly.

The provider's most recent fire risk assessment was completed on 20 October 2025 and identified that the home was maintained to a satisfactory standard, with no remedial actions required at the time of the assessment. Evidence showed there were appropriate fire safety management arrangements in place, including maintained fire alarm and emergency lighting systems, clear escape routes, suitable fire safety training for staff and a plan of action that identified no outstanding fire safety actions.

The provider had invested in the environment, including a refurbished sensory room, improved communal areas and a newly refurbished medicines room to support the safe storage and administration of medicines.

People were actively involved in decisions about their environment; for example, people chose colours and layouts for communal areas and their sensory room, and staff used social stories and colour charts to support people to understand options and make informed choices. A new wellness building was also being developed in the garden to provide opportunities for exercise and wellbeing activities, supporting people to maintain healthier lifestyles.

Overall, the environment promoted people's safety, comfort, independence and wellbeing.
 

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.

At the previous inspection, there were concerns that people were not always supported by enough staff with the right skills, knowledge and training to meet their needs safely. During this assessment, we found significant improvements. Safe recruitment processes were being followed, including appropriate pre-employment checks, and staff received regular training, supervision and competency assessments. Staffing levels and workforce stability had improved, helping to provide people with more consistent support.

Staff demonstrated a good understanding of people's individual needs, medicines management, safeguarding, epilepsy care and Positive Behaviour Support. The deputy manager had delivered additional person-centred training to support staff to use proactive and the least restrictive approach when supporting people with complex needs. Staff spoke positively about the changes made, with one member of staff telling us, "We have good staff which makes it easier" and another saying, "I definitely feel supported." Relatives also described improvements in staffing consistency, with one relative commenting there was now “a core staff of three main carers who seem to be doing a good job." These improvements helped ensure people received safe, effective and consistent support from a skilled and confident staff team.

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.

At the previous inspection, concerns were identified regarding cleanliness and the management of infection prevention and control risks (IPC). During this assessment, we found significant improvements. The service was clean, well maintained and supported by a dedicated housekeeper who demonstrated a good understanding of IPC procedures. They told us, "We have separate mops, buckets, mop heads are disposable and red bags for washing. We have gloves, aprons and masks available to use if needed. I put dirty washing to the side of the machine, clean on the table and take it straight out of the laundry to avoid any cross contamination."

Staff received IPC training and the provider completed regular audits to monitor standards and drive improvement. We observed clean communal areas, bathrooms and kitchen facilities, and found people were living in an environment that was clean, safe and well managed.
 

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.

At the previous inspection, concerns were identified regarding medicines management, oversight and the safe storage of medicines. During this inspection, we found significant improvements. Medicines were stored safely within a dedicated medicines room, and room temperatures were maintained within the required range through the use of an air conditioning unit, supporting the safe storage of medicines.

Regular medicines audits, stock checks and staff competency assessments were completed to promote safe practice and oversight. Staff demonstrated a good understanding of medicines management and medicines records were well maintained.

During our inspection, we identified a discrepancy in the reconciliation of 2 people’s as required (PRN) paracetamol; however, the registered manager took immediate action to investigate and address the issue. This demonstrated an open and responsive approach to medicines governance and continuous improvement.

Overall, medicines systems were well managed and people received their medicines safely and as prescribed.