Martlet Manor

Updated 13 April 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of 3 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Martlet Manor is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Martlet Manor is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. There was no nursing care being provided at the time of this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 10 people and 5 relatives about their experiences. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with 17 staff including the registered manager, the deputy manager, 3 nurses, 9 care workers, the wellbeing champion, the chef and the operational support manager. We looked at records relating to care provided, staffing and management systems.

Updated 13 April 2023

About the service

Martlet Manor is a residential care home providing personal and nursing care to up to 72 people. The service provides support to older people including those with dementia and younger adults with physical disabilities. At the time of our inspection there were 52 people living at the care home. The building was purpose built and had adapted facilities on 3 floors. The service was not providing nursing care at the time of the inspection.

People’s experience of using this service and what we found

Risks to people were not consistently managed and this had put people at risk of harm. Medicines were not kept securely and potentially harmful substances were not stored safely. The registered manager took immediate actions to address these shortfalls.

The service had vacant positions and used agency staff to ensure safe staffing levels. An active recruitment programme was in progress. Some staff, who were new to the service, had not received all the information they needed to keep people safe.

Staff did not always protect people’s privacy and systems for managing laundry were not effective. This had a negative impact on people’s dignity.

Management systems for monitoring the quality of the service had failed to identify and address these concerns.

The provider had a system for managing complaints but not all concerns were identified and responded to. We have made a recommendation that the provider reviews their complaints system.

People spoke positively about the staff and described them as kind and caring. They told us they were happy living at the home. One person told us, “We’re a happy bunch of soldiers. You couldn’t get better at a 5 star hotel. It’s a nice place to live.” Another person said of the staff, “They are all caring people.”

The registered manager was passionate about creating a community spirit at the home. It was evident that many people had developed friendships and were engaged with the social life of the home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Assessments and care plans were well personalised, detailed and comprehensive. Records reflected the care people were receiving. People were supported to access the health care services they needed, and staff worked effectively with other agencies.

The registered manager used quality assurance systems to identify areas for improvement, including analysis of incidents to support learning and improve practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection This service was registered with us on 15 October 2021 and this is the first inspection.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to assessing and managing risks, supporting dignity and respect and monitoring the quality of the service, at this inspection.

We made a recommendation about reviewing systems for managing complaints and reviewing administration of medicines.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.