Archived: Marine View Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment, the rating has remained requires improvement. This meant the management and leadership was inconsistent. The registered provider was in breach of legal regulation in relation to good governance.

This service scored 61 (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 shared vision, strategy, and culture. The provider sought to provide person-centred and effective support for vulnerable people. All people connected with the service sought to achieve this from representatives of the registered provider to the registered manager and care/nursing staff. This shared direction was achieved following our observations of care practice and interactions between staff and people who used the service.

Information received prior to this visit indicated that some staff had concerns about some aspects of the culture of the service. This was raised with the registered provider and was investigated.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support. Representatives from the organisation visited on a regular basis to check and discuss quality issues.

There were mixed views from relatives about responses to issues they had raised. Some commented despite numerous and repeated requests, these were not always completed in a timely fashion. Other considered they were listened to. Evidence was available suggesting that a “You said, we did” process had been undertaken with people and their relatives.

The service had a whistle blowing procedure and policy for staff to refer to. These were on display within the service. Whistleblowing concerns had been made in the past with staff using the organisation’s whistleblowing process leading to investigations. We did receive feedback some staff did not always feel their voices had been heard.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The registered provider had an equal opportunities policy and avenues were in place for staff to express their views.

Quality audits were not always effective. Audits had been undertaken by both the registered manager and from a representative of the registered provider. A home improvement plan had been devised identifying ongoing issues needing to be addressed. Recording of progress with issues was not always completed. From January to March 2025; 6 actions remained open with no indication of progress or if they had been addressed.

The registered manager used daily walkarounds to comment on aspects of the quality of support provided and the environment. Walkarounds had not identified issues we found during the inspection in relation to cleanliness, safety, and medication. We did not see any evidence of manager’s dining audits to ensure quality. In addition, any shortcomings identified during the first day of our inspection had only been partially addressed.

Monthly medication audits were undertaken. These included a rating of the efficiency of medication systems on each on the four floors. All were assessed as being good for March and part of April 2025. Any actions required were passed onto nurses employed on each floor. One record did not include who the issues had been raised with. None of the medication audits concurred with our findings with medications.

The provider’s governance systems had failed to identify and prevent an inappropriate arrangement in which overseas workers were accommodated within the service alongside people using the service. This arrangement had not been subject to appropriate scrutiny and oversight. During the time this arrangement was in place, a health and safety risk assessment had not been completed to identify and implement measures to mitigate risk to people. Although the overseas workers were no longer living in the service at the time of assessment. This arrangement had compromised professional boundaries and introduced potential avoidable risks to people.

The provider understood their duty to collaborate and work in partnership. Other agencies told us they were happy with the level of engagement between themselves and the service. They were able to provide an indication of how the needs of people they were involved with had changed.

Despite having systems and records available to improve and maintain the quality of care, the provider did not always focus on continuous learning, innovation, and improvement across the organisation. Where concerns had been identified through the quality processes used by the registered provider, records did not always reflect action had been taken to address these. This was noted in the home improvement plan. While many issues had been identified and rectified, 6 historical actions were still open.

We identified issues with the safety of some aspects of the building and infection control. On our second visit, 6 days later, these had only been partially addressed.