Marigold Nursing 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.

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. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had systems for logging and investigating falls, incidents, accidents and safeguarding concerns. Although incidents were analysed, the analysis was not detailed to enable lessons to be learnt effectively when things went wrong.

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’s needs had been assessed when they moved to Marigold Nursing Home.

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.Safeguarding concerns had been referred to the local authority safeguarding team and investigated.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests (BI) and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

The provider was meeting the requirements of the MCA. DoLs authorisations had been approved or applied for. The provider had a DoLs matrix to ensure DoLs authorisations were renewed on-time.

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.

Risk assessments had been completed, where required. However, some needed further development to ensure they were personalised and clearly identified measures to reduce risks to people. For example, choking risk assessments did not detail what strategies staff should follow to achieve the goal of reducing the risk of choking.

A downstairs dining room was being used as storage. The area was not locked and there was no signage to alert people to the room being out of use. The provider had not been proactive in assessing the potential risk of harm to people, as the risk assessment for this was not completed until after our inspection started.

The provider did not detect and control potential risks in the care environment. They did not make sure equipment, facilities and technology supported the delivery of safe care. Restricted areas of the home were not always secure to prevent people from accessing them unknowingly.

Most health and safety checks were up to date. However, the provider had not acted swiftly to deal with issues identified. Health and safety checks had identified 15 extractor fans in people’s rooms had been broken for over 3 months without action taken to address this. The provider acted to deal with this issue while we were at the home and had arranged for fans to be replaced.

Repairs had not been actioned timely, such as a broken fire door and a broken greenhouse window.

Daily environmental checks were not carried out consistently. Fire safety measures needed improving as items, such as wheelchairs were stored in stairwells and fire drills had not been carried out regularly.

The provider was making environmental improvements in the home and had recently completed the refurbishment of the first-floor communal lounge.

There were not always enough qualified and experienced staff to meet people’s needs. The provider did not always make sure staff received effective support, supervision and development. Staff did not always work together well to provide safe care that met people’s individual needs. People, relatives and staff gave mixed feedback about the number of staff on duty. A person said, “They (staffing levels) have gone down since a few months ago.” A staff member deployed to provide one to one support to a person was also supervising the communal lounge alone at times during the day. A staff member commented, “They have reduced staff on the floor. It is a struggle, we have loads of people we have to get up. We are always in a rush.”The provider did not ensure all staff were adequately trained as 2 staff had been working at the home for a significant period without completing their basic training. Improvements were needed to ensure new staff were recruited safely, as not all required checks were completed.

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 up to date infection prevention and control (IPC) policies and procedures. Staff had also completed training in promoting good IPC.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Although medicines were administered appropriately, management had not been proactive in monitoring staff had maintained their skills and knowledge. All medicines competency assessments had expired. The provider had not acted in a timely way to ensure these had been redone.