Archived: Marine View Lodge

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 requires improvement. At this assessment, the rating has remained 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 people could be harmed.

The registered provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 62 (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 initially demonstrate a proactive and positive culture of safety. During our first visit, some unoccupied bedrooms on the ground floor were used as storage areas containing several unused items such as paint, cardboard boxes, bedframes, and mattresses. Doors to these areas were not locked and were accessible to anyone therefore creating a risk of physical injury. We requested these either be removed or doors locked following our first visit. On the second day these areas were still accessible, although some items had been removed. The provider subsequently provided evidence to us that this had been addressed.

There was a system in place to record and monitor accidents and incidents. Accidents and incidents were reviewed on a regular basis by the management team. Appropriate actions were taken following accidents to ensure the health of people were promoted. Where necessary, some accidents resulted in the need for other agencies to be contacted for advice, review, or information. The registered provider demonstrated this was done regularly. Records enabled them to analyse trends and identify any 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 provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. For example, the registered provider “engaged well” with the end-of-life teams to ensure that people were supported in the last stages of their lives.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Systems were in place to protect people from the risk of abuse. Staff received training and understood the actions they must take. Guidance on safeguarding processes were also available to staff. if they felt someone was being harmed or abused. Referrals had been made to the local authority safeguarding team when abuse had been suspected, and investigations had been completed. In addition, concerns not meeting the threshold for more significant investigations were reported to the local authority monthly. These care concerns provided evidence of actions taken as a result.

The provider worked with people to understand and manage risk. People’s needs were appropriately assessed. Risk assessments had been completed and detailed care plans had been developed to minimise any risk to people’s health and wellbeing. Throughout our visit, we observed safe working practices, such as moving and handling of people being carried out

The provider did not always detect and control potential risks in the care environment.

We saw bedrooms on the ground floor whose doors were unlocked with rooms containing bedframes, mattresses, paint, cardboard boxes, and other
miscellaneous items. Given these doors were not locked they posed a potential hazard to anyone walking into the room. Although there was only one person residing on this unit, we requested these items be cleared by our next visit.
The provider was responsive to feedback given and ensured the rooms were removed of all hazards. Handwashbasins in toilet areas had unlocked vanity units which contained several cleaning materials. These were removed by the second day of our visit. A lounge area on the ground floor had a cabinet which contained personal protective equipment and continence aids. Appropriate checks had been carried out in respect of systems such as fire, water temperatures, legionella, portable appliances, and equipment.

The provider made sure there were enough qualified, skilled, and experienced nursing and care staff, who received effective support, supervision, and development. Staff rotas were in place indicating a sufficient mix of qualified, skilled, and experiencedcare workers being available in sufficient numbers for people to be supported each day.

Relatives were positive about the approach staff used in supporting their loved one. Agency staff had received appropriate induction, and the registered provider had systems in place to check their right to work as well as nurse registration and training details. Staff were recruited appropriately.

The provider did not always assess or manage the risk of infection. While most areas were clean and hygienic, some were not. Dishwashers were installed in kitchenette areas in each living area. Door seals and interiors of these were not clean and in one appliance, an odour which appeared to be from stagnant water was evident. A relative told us these had not been used for at least the past twelve months, but they had not been removed.

Some bins in toilets and bathrooms used for general waste contained used personal protective equipment. We alerted the registered manager to this, and this was addressed. Waste bins in kitchens did not open using the foot pedal. In kitchens, draining boards, taps and plates had not been thoroughly cleaned.Some settees in lounges and carpets in bedrooms were noted to be stained. Food stored in domestic refrigerators was not labelled and jugs of juice available did not always have a date to indicate when the drink had been prepared.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Strict legal controls are needed for certain medicines. There are referred to as controlled drugs (CDs). Some people living at Marine View had been prescribed CDs. Controlled drug registers were not always accurate. A registered nurse employed at the service corrected this during our visit.

Some medicines were required to be stored in refrigerators. Bottles of medication had been opened and were both in use. In addition to this, there was no indication of the date when these had been opened.

Some people had been prescribed medicines which were given as required (known as PRN). Protocols were in place for staff to refer to so they could be administered consistently. Protocols for medicines prescribed to reduce anxiety and distress experienced by people were in place as well as administration recorded. The recorded reasons for administering these medicines were vague and did not provide an indication as to whether staff interventions had been used in the first instance to relieve this anxiety. Recorded outcomes as to the effectiveness were either omitted or were basic.

One tablet was found down the side of one armchair cushion in a lounge. We alerted the registered manager to this who took appropriate action. After consultation with the pharmacy supplier, it was concluded the origin of the tablet was not linked to any person living at Marine View Lodge.