Martindale Road

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

We identified breaches of Regulation in relation to safe care and treatment, safeguarding people from abuse, staffing and good governance. We found aspects of the service were not always safe. The provider did not always analyse, investigate, or learn from things that went wrong. Systems to ensure people were safe from harm or abuse had not always been followed. Staff did not always ensure the environment was safe or clean. People received their medicines safely and as prescribed. However, improvements were needed in some protocols and information about medicines to make these clearer. Staff did not always have the skills and knowledge needed to care for people or meet their needs. The provider was trying to address this by organising additional training and support for staff.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People did not always experience good quality care because lessons had not been learnt when things went wrong.

Staff told us they did not have opportunities to discuss accidents, incidents, complaints, or other adverse events or to learn from these. They said they lacked guidance and support about responding when a person was physically aggressive or how to respond to other incidents. They knew how to report things that went wrong.

Staff completed reports of accidents and incidents. However, these records did not show how the event was investigated, analysed, or learnt from. Records to describe when people experienced self-harm and agitation only gave a basic description of what had happened and did not include information about potential triggers, consequences, or outcomes. This meant they were not useful tools to learn from or to improve the service.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People had not always been protected from poor care or treatment. An incident of alleged abuse which took place in December 2023 was not investigated or acted on until June 2024. This meant people had been placed at risk of further abuse and poor treatment.

Staff told us they had received training about safeguarding and knew who to report concerns to. However, they also told us concerns they had raised with managers had not always been acted on.

Staff supported people in a safe way during our visit.

The procedures for safeguarding people from abuse had not always been operated effectively. Staff had not always felt able to speak up about concerns and when they had, these had not been investigated. People had experienced poor treatment and abuse and staff did not always have the skills to understand about best practice. This placed people at risk of poor care or treatment. The regional manager had identified procedures had not been followed. Shortly before our assessment, they had started the process of investigating historic concerns. They had liaised with the local authority safeguarding team and arranged retraining for all staff. They had put in place measures to help protect people from further harm.

Risks to people's safety were not always well managed. People had experienced poor care with staff not following best practice or guidance. Staff did not have the skills or understanding to support a person who routinely injured themselves. This meant the person was not receiving the right support to keep them safe or meet their needs.

The provider told us they had a programme of staff training which included how to support people in a person-centred way and how to respond to challenging situations. However, some staff explained they did not have enough guidance and wanted more training to understand who to support people who harmed themselves. They had received training to understand how to move people safely.

We saw staff supporting people to eat and drink in a safe way and to move safely.

The provider had developed risk assessments to outline how people should be supported. These had not always been followed which put people at risk. The provider had identified this and had arranged for urgent training in some areas to help make sure staff understood how to manage risks to keep people safe. One person's individual emergency evacuation plan had not been updated to reflect changes in their mobility. Two people's plans were not stored in an accessible place where they could be shared with emergency services if needed. This meant there was an increased risk in the event of a fire.

People lived in a generally well-maintained environment. They had the equipment they needed to stay safe within the home, although 1 person was waiting for a new wheelchair to help them move around more freely and safely. Some equipment, including a bath needed to be replaced.

Some staff could not describe the safe systems for evacuating people in the event of a fire. They told us they had undertaken training and we saw that fire drill practices had taken place. However, they lacked an understanding of how to respond safely or how they would support people. The regional manager explained they had identified where improvements were needed for the building and had an action plan to address these areas.

One cupboard containing cleaning products had not been locked or secured. The risk of people accessing this were minimal, however the items should have been secured in line with the provider's procedures. Other risks within the environment were managed. The corridors and rooms were spacious and designed to meet the needs of people who used wheelchairs. Some areas of the building were personalised and there were some areas which included tactile or sensory items.

The staff undertook checks of equipment and the environment. They acted when they identified something was wrong. The provider arranged for external companies to carry out safety checks as needed.

A relative we spoke with told us they did not feel staff had the skills needed to care for people well or safely. They told us staff lacked direction and guidance. People sometimes experienced poor care because staff did not understand their needs. The provider explained that staff undertook a comprehensive programme of training. However, we found staff did not always apply this learning when providing care. Some staff told us they did not understand how to effectively communicate with people or how to keep people safe in some situations. This meant the provider had not always deployed sufficient numbers of skilled staff to meet people's needs.

The staff told us they did not always feel supported. They felt there were not enough of them. One staff member said, ''Staffing should increase because the work is physically heavy.'' Another staff member told us, ''We have had not training about how to communicate with [people who do not use words]. Some people are difficult to manage because they scream and self-harm, we have not had support to know how to respond to this.'' Another member of staff said, ''We are not supported, we cannot discuss things with our manager.'' The regional manager told us they had recognised staff needed additional training and had organised for some of this to be undertaken urgently. Following our visit to the service, the provider shared evidence this training was taking place.

Staff did not always demonstrate the right skills to support people. They did not communicate effectively with them or demonstrate an understanding of person-centred care

The systems for staff support had not been operated effectively. Staff felt unsupported and had not had clear direction or management. They did not have opportunities to reflect on their work or have their knowledge discussed or tested. The regional manager had recognised this had not taken place and had developed a plan to help provide better staff support in the future. The provider had systems to help make sure only suitable staff were recruited. They provided a thorough induction for new staff which included a range of training and shadowing experienced workers. The staff had undertaken a range of training courses. Staff had the skills to provide basic care, including supporting people to move and helping them with personal care.

Staff demonstrated a good understanding of infection prevention and control when supporting people. For example, they washed their hands and used disposable gloves when needed.

The staff told us they had undertaken training to understand about good infection prevention and control. They explained they had enough personal protective equipment (PPE) and understood about good hand hygiene.

The environment was generally clean; however, we found some areas where there was an increased risk. For example, the freezer needed defrosting, the oven extractor fan was greasy and dirty, and some food had not been properly stored or labelled. The service had run out of some essential supplies, for example paper towels, before our visit. These had been ordered and arrived during our visit.

There were procedures for staff to ensure the building was cleaned and to carry out checks on cleanliness. These had not always been followed appropriately because we found areas where improvements were needed. The regional manager had updated procedures to help make sure stocks of equipment were ordered in a timely way and did not run out in the future and to ensure that cleaning procedures were being followed consistently.

People received their medicines safely and as prescribed. Staff demonstrated good practice when administering and handling medicines. However, staff were not able to tell us what the medicines they were administering were used for. This information was recorded, but staff had not always familiarised themselves with this.

Staff told us they had undertaken training to safely handle medicines. They were able to describe the procedures they needed to follow.

We found some discrepancies in medicines records. These were recording issues, and we were assured people had received their medicines as prescribed. There were protocols for the administration of 'as required' medicines. These were detailed and personalised but had not been agreed by the prescribing healthcare professional. We discussed these issues with the regional manager so they could address these. There was information for staff about different medicines including what these were used for and any potential side effects. There were risk assessments, guidelines, and records to monitor people's health and wellbeing. People had their medicines reviewed by healthcare professionals. Medicines were safely stored.