Marian 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.

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 people’s safe care and treatment and premises and equipment

This service scored 47 (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.

Incidents and accidents were recorded; however, these records did not include analysis, reflective review, or consideration of underlying causes or emerging themes. There was no evidence that information about incidents was being used to identify learning, implement improvements, or prevent reoccurrence. This limited the provider’s ability to recognise patterns of risk and to embed safer practice. For example, incidents where a person had become distressed were not analysed to understand underlying trends and themes.

Staff we spoke with understood their responsibility to raise concerns and report incidents and accidents. People told us they were supported by staff who knew them well and relatives told us they felt confident to raise concerns.

During the inspection the provider took action to improve incident and accident records to demonstrate lessons learnt.

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.

The staff team and managers told us they worked well with other professionals to ensure continuity of care. Healthcare professionals told us they had a good working relationship with the service and communication was good. Relatives stated they were informed when their family members required support or treatment from different agencies.

People had hospital passports which included details about how best to communicate with the person, important contacts, medicines and their physical health and emotional wellbeing needs.

People who used the service had lived there for many years. The staff knew them well and understood their needs and wishes.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them 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 bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider failed to have a robust policy and procedure for supporting people with their finances. The robustness of the arrangements in place for people who needed support to manage their finances had not been fully assessed, and this increased the risk of financial abuse for people.

Deprivation of Liberty Safeguards authorisations had been applied for, and some authorisations received. However, there was no formal system in place for the oversight of these and to track any conditions, relevant persons representative and expiry dates of authorisations. The registered manager told us they were implementing a more robust system so this information could be tracked and monitored more effectively.

The provider shared concerns appropriately. People were comfortable and at ease with staff. Staff were attentive. Staff demonstrated a clear understanding of their roles and responsibilities in relation to safeguarding and reporting concerns. A member of staff told us, “Any concerns I have I would tell the manager, they are very approachable and they would sort things out.” Another staff member told us, “There was some concerns a long time ago, I raised this with the manager, and it was dealt with appropriately.”

The registered manager was aware of their responsibilities in ensuring people were protected from abuse. The provider had policies and procedures in place to guide staff on how to respond to any allegations of abuse. Records confirmed that staff had received safeguarding training, which supported their knowledge and understanding of how to keep people safe.

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.

Where people could become anxious, distressed and exhibited behaviours that could place themselves and others at risk of harm the care plan and risk assessment lacked guidance for staff to follow. These records failed to provide staff with clear guidance on the techniques and strategies to use when responding to such incidents. A Positive Behaviour Support plan (PBS) was not in place for the relevant person; these are plans that enhance people’s life while reducing the likelihood of distressed behaviour.

Some people had been assessed as needing help from staff to mobilise from their bed to a wheelchair. However, moving and handling plans were not in place to guide staff and mitigate any associated risks. These plans should state what people can do independently, how their disability impacted on any moving and handling transfers and how they could cooperate with the transfer. They should also include what help they needed from staff to safely reposition themselves and how staff were to make safe use of the specialist equipment in place, such as mechanical hoists, slide sheets and shower chairs. This increased the risk of harm to people and staff from unsafe moving and handling practice.

Some people’s care records lacked detail about how they were supported with specific health conditions including cerebral palsy and sensory impairment. There was no care plan or risk assessment in place to explain how the health condition affected the person or how staff could recognise any risks associated with the condition. This increased the risk of harm to people and of specific needs not being met.

Whilst risks were not well documented, the registered manager told us they were working on improving people’s care records and risk assessments and ensuring all the required information to guide staff on how people wanted to be supported was in place. Staff knew people’s needs well and had received face to face training on moving and handling.

The provider did not always detect and control potential risks in the care environment. Arrangements to monitor the safety and upkeep of the premises were not always effective to support the safe delivery of care.

A number of windows above ground floor level had restricted hinges that limit the opening of a window. These are now deemed not suitable in health and social care premises where people are identified as being at risk of falls from windows. The provider’s regular checks on window restrictors had not identified they were no longer compliant. We shared the current guidance with the provider, and they took action during the inspection to address these.

People were at risk from some environmental hazards that had not been identified and managed through the provider’s own systems. We saw trailing leads from a plug adaptor near to the dining table where people were sitting and these presented a trip hazard. Storage in people’s rooms had not always been well managed and the risks had not been considered. We saw boxes stacked in people’s rooms, by doorways, next to a bath and on top of cupboards and wardrobes, and there was a risk of items falling on people.

Fire safety arrangements were not robust. Fire safety checks had not always been completed weekly in accordance with the provider’s own fire safety assessment. These checks were 5 weeks overdue when we inspected. Fire drills did not include any details of the staff members involved in the fire drill. This meant participation in drills could not be monitored and no fire drill had taken place with night staff. The fire floor plan had not been updated to reflect the change of use of a room. These are used by firefighters during an incident to assess safety and the source of an incident. People had Personal Emergency Evacuation Plans (PEEP’s) in place, but these lacked detail about their specific needs and the level of support they may need in the event of a fire. Work had recently taken place to replace several fire doors throughout the home, so they were compliant with current fire regulations.

The premises had not always been developed with the needs of people, and national best practice considered. The layout and design of the home did not always maximise the choice, control and independence of people. Consideration had not been given to the sensory needs of people with a learning disability.

The provider did not always make sure there were robust systems in place for ensuring safe and effective staffing.

There were inconsistencies in how the provider’s recruitment practices were implemented. For example, staff identification documents which were not consistently witnessed, signed or dated. Where different references were sought from those recorded on a job application form, there was no clear rationale and no audit trail explaining the decision-making process.

People were supported by the same group of staff members who were familiar with their care needs. This helped with consistency and continuity of care as staff were aware of the needs of people they were caring for. The registered manager told us there was no formal system in place for assessing staffing levels and not all staff had completed practice fire drills. Most staff told us staffing levels were adequate; however, a few staff told us additional staff in the late afternoon would benefit people’s care and opportunities for spontaneous visits outside of the home.

The provider had a training plan in place to ensure staff had the skills and knowledge required to meet people’s needs. Staff completed training in key areas including moving and handling, infection control, and fire safety. Staff had also completed training specific to supporting the needs of people with a learning disability and/or autistic people. However, the provider had not implemented a system for assessing staff competency, but plans were in place for senior staff to complete this training. The registered manager told us staff competency assessments would then be implemented. The registered manager told us a new induction process was in the process of being implemented and would be more detailed and ensure staff were well supported when commencing in their role.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

There were a number of bags and coats hanging above a table where people sat to eat their meals, and this presented a potential safety and hygiene risk. Also, several dining and lounge chairs had worn areas on the fabric and cleaning of these had been compromised. There was an increased risk for bacteria to thrive in the worn areas of chair covers and an increased risk of contamination. The provider addressed both issues after day 1 of our visit. These issues had not been identified by their own infection prevention and control (IPC) audit.

The provider had an IPC policy, and staff had completed IPC training. The environment was clean, and regular cleaning took place throughout the day. Personal protective equipment (PPE) was available for staff to use when needed.

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.

The registered manager told us they had made a number of recent improvements to their medicine management arrangements. This included a new medicine room being developed and a new pharmacy was supplying their medicines. They told us they had not yet implemented staff competency assessments or regular audits, but these would be implemented soon.

People’s medicines records we reviewed were up to date and medicines were stored safely and securely. Staff had completed medicine management training. People’s medicines were reviewed by the GP and the registered manager was aware of the national STOMP (Stopping over medication of people with a learning disability and autistic people) project.