Marina View Care Home

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• 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

We found 2 breaches of the legal regulations. People were not always supported to take their medicines safely. Staff were not always recruited safely which left people at risk of harm. People's risks and needs were not always assessed adequately, and we have included this as a breach in the well-led section of the report. There were some gaps in the maintenance records for the home. Although there were safeguarding processes in place, there were a high number of safeguarding alerts. However, health and safety checks had been made, and the environment was clean and comfortable. People were protected from the risk of mistakes as improvements had started to be made in processes and staff knowledge.

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.

Improvements had begun to be made in monitoring people's experiences such as falls. We received feedback from relatives that a person had fallen in the shower due to inappropriate equipment. It was not clear whether this had been identified as an incident at the time and whether lessons had been learned.

Leaders had begun to make improvements in their monitoring and analysis of incidents, but this was not embedded. Staff we spoke to knew to complete incident forms. However, they confirmed there was a lack of debriefs to ensure lessons could be learnt and re-occurrences prevented. A staff member said, “There are no debriefs. We are never asked and there’s no follow ups following incidents or accidents.” Most staff said they were supported to raise concerns and would not be blamed or treated negatively if they did so. However some staff felt unable to raise concerns.

There was an up to date incident reporting policy, but the process was not embedded.

Not everyone had a pre-admission assessment in their care records. People told us about poor experiences during admission. A relative told us they raised concerns about equipment and size of bed whilst the person was still in hospital, and the person was admitted before this had been resolved. A relative told us, "When [my relative] was first admitted, there were 2 relief managers there and all agency staff which led to a lack of consistency in everything. I feel that things are starting to improve with more regular and experienced staff." People told us that what was advertised as being available was not once their relative moved in.

We found that not everyone had received a pre-admission assessment, and where they had, some did not contain sufficient detail. The new manager was aware of this and actions were being taken to address and improve processes. Staff were not always involved during the referral and admission process. The new manager planned to involve care still in the admissions process. Some staff told us they did not have time to read care plans or risk assessments in full when people moved into the home. A staff member said, “We don’t get to know the needs of new admissions straight away.”

Partners shared concerns about admissions, and felt that staff had not received the right training to care for people with complex needs. The local authority recently placed a suspension on new admissions whilst improvements to admissions processes and staff training could be made.

Although there was an admissions process, this had not been followed effectively, leading to problems. The new manager had put plans in place to address, which will be monitored by partners.

People told us they felt safe at the service. Relatives felt that although they thought people were safe, staff training could be improved.

There was a basic system to keep a list of recent safeguarding concerns. However, the new manager was required to re-visit previous safeguarding alerts and investigations to make sure that any guidance and recommendations was captured and acted upon. This was in progress at the time of the inspection. Leaders and staff told us there had been a high number of safeguarding alerts. We received mixed feedback about safeguarding training, although most staff had a strong understanding of safeguarding and how to take appropriate action. A staff member told us, “I would report anything that I felt shouldn’t be happening.”

The manager supported people, relatives and staff to understand safeguarding and how to raise concerns about themselves or others. We observed posters containing relevant information in communal areas. We observed staff supporting people to make their own decisions in line with The Mental Capacity Act 2005 (MCA). For example, asking people what they would like for lunch, what they would like to do or where they would like to sit.

There was a safeguarding policy and staff knew what to do if they had concerns. The manager was strengthening existing systems but this was not embedded.

We received mixed feedback about people's experiences. Some people and relatives told us they were involved in planning their care, whilst other relatives told us they had not been, and felt there were missed opportunities to give relevant information from the start as a result. A relative said, "I wasn't involved in drawing up my [relative's] care plan. I have attended a review meeting this year."

Staff told us they had not received any training around managing behaviours of distress. As such, we could not be assured staff could respond to people appropriately when they were communicating their emotions or distress; or manage situations in a positive way that would protect people’s rights and dignity.

Staff understood people’s mobility needs and we saw staff supporting people to move around the home safely. We observed specialist equipment and adaptions in place for a person who could not communicate their needs verbally. People were informed about risks and were supported to keep themselves safe. We saw safety signs throughout the home and measures in place to manage risk. Staff were alerted to emergencies by call bells and alarms.

There was a policy in place to make sure that risk assessments and care plans were completed timely, and that reviews of care occurred monthly or when there was a change.

We received mixed responses about people's experiences. Some relatives thought that equipment was not right for people, and they spoke of a lack of equipment being available at times, although they added this was addressed when they raised it. A relative told us, “There was meant to be equipment provided. However, it had to be brought from home because there was none available to support [relative's] needs."

We found gaps in some aspects of maintenance management and environmental checks. Leaders told us they had recently appointed a new maintenance manager who would be responsible for embedding more robust systems. Most staff had no concerns about the environment or the safety of people at the home. However, a staff member fed back that they felt they did not have the skills to support an emergency evacuation due to the lack of fire drills. Others spoke about long waits to get things fixed and the impact this had on staff and people living at the home.

The home looked well maintained and the environment had been designed to meet people’s needs, with plenty of facilities such as a salon, cinema room, adapted bathrooms and several communal living areas. We observed various measures in place to help keep people safe and secure. For example: wardrobes were fitted to walls to prevent entrapment and people had access to call bells in case of falls. External doors were secured with keypad locks and alarms; and doors to the kitchen, laundry room and sluice rooms were inaccessible to people to help prevent incidents. We noted firefighting equipment available throughout the home and appropriate safety signage. The equipment available to deliver care and treatment seemed suitable for the intended purpose. Bath hoists were in place and seemed in good condition, handrails and hoists were available and people were observed using a variety of wheelchairs and walking frames.

Improvements to maintenance management systems were required. Environmental risk assessments had not been completed for most areas of the home. We could not see any evidence that maintenance checks had been made. We did not see whether regular checks had been made to water outlets in empty bedrooms to prevent legionella, and fire safety systems were not consistently checked. The local fire service made recommendations earlier this year. It was not confirmed whether action had been taken to address their concerns. However, improvements had been made to training staff around fire safety and we were informed the fire drills would be held more frequently. Health and safety checks such as gas and electrical wiring testing had been made.

People and relatives thought that the service would benefit from more staff, and that staff required more, in-depth training to support them to do their roles. One relative said, "I don't understand why the staff swap units. It causes problems both with continuity and lack of familiarity for people living with dementia."

Staff told us that staffing levels were usually consistent, however certain times were more challenging if people required 2-1 support, which many people did. Leaders felt there were sufficient staff to meet people's needs.

We saw evidence of a skills mix at the home to help make sure people received safe, good quality care. A range of managers, registered nurses, care staff, auxiliary staff and administrators were on shift throughout the inspection. However, we observed a newer member of the team providing 1-to-1 support to someone in the community, without the appropriate training or experience; and the service had not considered potential risks. On the 2nd day of the inspection half the care staff on shift were agency workers. People and relatives told us they felt agency staff had less knowledge about people's needs and preferences.

Recruitment practices were not always safe. Application forms were not always completed in full, and some staff had not recorded their full employment history as per best practice guidance. A senior carer had commenced employment prior to their references being received, or their Disclosure and Barring Service (DBS) being checked. DBS checks provide information including details of convictions and cautions held on the Police National Computer. Staff did not always receive training appropriate and relevant to their roles. There were several gaps in the training matrix and the induction records we reviewed had not been fully completed. Only a handful of care staff had received learning disability training despite this being mandatory since 2022. Although no harm was identified, people were at risk of harm due to systems not being in place to ensure safe recruitment of staff. This was a breach of the regulation. The new manager assured us this would be addressed immediately and all recruitment files would be reviewed. Appropriate staffing levels were not always maintained. When reviewing rotas over 2 months, a number of shifts had not been fully staffed including 1 shift in which no registered nurse was available.

People and relatives thought that the home was clean and tidy. Several relatives told us they had to request that people were supported to have a shower regularly to maintain personal hygiene. We fed this back and the new manager took action to address.

There were clear roles and responsibilities around infection prevention and control. Housekeeping staff confirmed that the department was fully staffed, and they had enough time to carry out tasks related to keeping the home clean. A member of staff who worked in the laundry room spoke confidently about how they separated soiled items and maintained good hygiene. Care staff told us they were allocated to support people with their personal hygiene.

People were generally protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. The home smelled fresh and was observed to be clean and well maintained, with housekeeping and laundry staff on shift. The laundry room was clean, tidy and well-organised with a good clean to dirty flow. Dissolvable bags were used for soiled laundry and hazardous waste bins were available. People looked well-presented and personal protective equipment (PPE) was situated throughout the home.

There were processes and cleaning schedules in place.

We found some issues around people's prescriptions being available at the right time. Relatives told us they had to chase up some issues, such as medicine being in liquid form rather than tablets. Other people told us they were supported to take their medicines safely.

Leaders were open and honest about the high level of medicine errors recently. This had been identified prior to the inspection and was already being addressed by recruiting clinical leads and registered nurses. Staff told us that the manager had recently begun to check their medicine competency levels.

People were not supported to take their medicines safely. Medicine care plans lacked sufficient information to guide staff about how to support people with their medicines. We found drink thickener stored in unlocked cupboards accessible to people. Thickener is added to the drinks of some people who have been assessed as being at risk of choking. This can cause harm if ingested accidentally. Topical creams were not stored securely. Staff did not request medicine reviews for people that were taking 'as and when required' medicines on a regular basis, and information to guide staff about this was lacking. Staff were not monitoring the temperature of the medicine room correctly so we could not be assured of the effectiveness of some medicines. Some time specific medicines were not given with sufficient time intervals which may cause harm to people. There had been a high number of medicines errors. The lack of systems to make sure people were supported to take their medicines safely placed people at risk of harm. This was a breach of the legal regulation. The new manager had already begun to address and was in the process of recruiting 2 clinical leads and experienced nurses. The home was being supported by the local authority medicines team to help them address concerns.