Mariantonia House Residential Care Home

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

People were not kept safe. There were no robust procedures and processes to prevent people from being abused by staff or other people they may have contact with. We found safeguarding policies and procedures were not being followed leaving people at risk of abuse. Steps had not been taken to ensure people were protected from theft, misuse or misappropriation of money belonging to them. There were no records or assurances to explain how people's monies were spent or accounted for, leaving people at considerable risk of financial abuse. Risks to people had not been adequately assessed, monitored and reviewed. There were no systems to ensure safe administration of medicines. No systems to accurately record, monitor or learn from incidents or risks identified. Environmental risks had not been considered until identified by inspectors, and no systems to ensure essential maintenance and measures to protect people from potential harm were identified and actioned appropriately. Recruitment practices were not robust with essential checks not being carried out to ensure the suitability of staff. We identified 4 breaches of regulation in relation to safe care and treatment, safeguarding people from abuse, recruitment practice and staffing.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was not an open or positive culture at the service. The registered manager did not always allow for an open and unbiased approach to investigations into concerns raised. One of the people living at the service had made allegations of abuse, and as a result had been assigned advocacy services. The registered manager had contacted advocacy and had dismissed of the allegations. This meant no action was taken to review or investigate the concerns raised in a transparent way which encouraged learning.

The registered manger and staff told us that they had a culture that was open and supportive of people. The registered manager said action was taken to manage risks, however, acknowledged that there were no systems or processes to record, review and learn from incidents that have or may occur.

Policies and procedures relating to accident and incident recording were not effective. Staff had no clear system which supported them to report or record incidents. Managers did not have a clear process which supported the review of accidents and incidents to learn from them. There was also a failure to inform CQC of this alleged incident. The lack of governance and oversight in the service impacted on the effectiveness of a learning culture.

People, relatives and loved ones told us that they felt safe and secure living at Mariantonia House. However, there was evidence some people were at risk of financial abuse; not all people using the service had the understanding of this or an awareness of the impact upon them. Not all people who worked at the service either voluntarily or in a paid capacity had been safely recruited or had appropriate background checks conducted. This put residents at risk of potential abuse; however not all residents were aware of this situation.

Staff and leaders did not all understand the legal frameworks around how to keep people safe from abuse or neglect. For example staff and leaders did not have an understanding of the principles of the Mental Capacity Act 2005 (MCA). Where people need restrictions to their liberty to keep them safe, a Deprivation of Liberty Safeguards referral (DoLS) can be made following an assessment of a person’s capacity. Terminology used in the service was not empowering to people and did not reflect an approach that acknowledged people’s strengths or abilities. One person’s DoLS referral refers to them as ‘having a mental age of a nine year old’, another person is referred to as ‘having the mind like a child.’ There was no documentation to show assessments had been undertaken or the principals of the MCA had been fully explored. This was a breach of regulation 11 (Need for consent) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.

During our onsite visits we had concerns to how people were being safeguarded from potential abuse. We identified anomalies with 6 peoples financial records and made referrals to the local authority safeguarding team and the police sharing our concerns. We were unable to gather adequate assurances that people were safe from abuse during the site visit. The local authority and police are investigating these concerns.

Safeguarding processes were not effective. People in the service were not always kept safe from potential abuse. Staff had received training in safeguarding however, policies and procedures relating to safeguarding were not followed, and this left people at risk of further abuse. Processes were not followed which meant leaders could not be assured about the suitability of all staff to work with vulnerable adults. People’s finances were not managed safely, there were large cash withdrawals and spending that were not adequately accounted for. Whilst the safeguarding adults policy and procedures in the service identified these factors as signs of financial abuse no action had been taken to investigate or address the management of people’s finances. Where people reported safeguarding concerns, these were not investigated in line with the provider’s own policies and procedures leaving other people at risk of further abuse. This was a breach of regulation 13 (Safeguarding people from abuse) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as people were not adequately protected from the risk of abuse.

Relatives did not feel their loved ones were at risk; however leaders at the service did not disclose relevant risks to relatives such as environmental risks or risks from staff not being safely recruited.

We were not assured leaders and staff always considered risks to people and how to safely manage any risks. The registered manager did not have oversight of the risks linked to people's care. During this assessment, we found serious concerns about people not being safe and not receiving the care they required. We found concerns with staff understanding of safeguarding, fire safety, risk assessments, medicines and environmental risks. This meant people were placed at significant risk of being harmed and their health and well-being deteriorating.

Not all risk assessments were up to date and also lacked detail. One person who had been assessed as having choking risk factors had instruction from the speech and language therapy team (SALT) on how to prepare food and measures to take to reduce the risk of choking. This information was not in the risk assessments or care plans. One service user had been assessed as being a high falls risk, however there was no risk assessments or measures identified to mitigate the risk of falls. Some risk that had not been considered was identified during the assessment. It is a requirement by law to have specific Personal Emergency and Evacuation Plans (PEEPs), this is to ensure that in the event of a fire service users can be safely located and evacuated. These give staff and other agencies such as the fire service the information needed about mobility and access in the event of an emergency. There were no PEEPs in place for people at the time of our visit. The registered manager or staff had been not considered the potential impact on people in the event of a fire or emergency. This was a breach of regulation 12 (Safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as steps had not been taken to adequately reduce the risk of harm to people. After these concerns had been identified the provider took steps to ensure all people had a PEEPS in place.

Staff did not always have access to up to date policies to support them when undertaking risk assessments for people using the service. Leaders did not undertake audits of care plans therefore did not know if risk assessments were completed accurately, in the right timescales or kept people safe. There were no clear systems or review or oversight of risk assessment processes.

People told us they felt comfortable in the home surroundings. Relatives did not identify the concerns we found with the management of the home environment. However relatives and people using the service were not aware of the environmental risks identified such as heating pipes not being adequately covered, heavy furniture not being affixed to walls and fire safety issues as identified by the fire service.

The registered manager was not able to demomstrate how they were assured of the safety of the environment. They were unable to show us how they could identify then rectify any environmental concerns.

Steps had not been taken to consider or reduce environmental risks to people. During our site visit on 15 July 2024, we found Control of Substances Hazardous to Health (COSHH) materials, including products containing bleach in kitchen cupboards that were accessible to the people in the service. There were also large knives stored openly in accessible drawers in the kitchen. There were 2 gas hobs situated in the kitchen that were able to be switched on without any restriction and were in areas where people could access unsupervised. Fire safety management was not adequate to keep people safe. Fire extinguishers had not been serviced or maintained in line with legislation. Two fire extinguishers needed servicing before being suitable for use in a fire. The provider was unaware of these fire extinguishers needing attention. Fire doors that were labelled as needing to be kept closed were found open, with door wedges used to keep them open.

The provider had not recognised safety issues within the environment, there was furniture that was not secured in people’s rooms and this posed a risk of falling onto people. No consideration had been given to the fitting of window restrictors, and there were no risk assessments to indicate if these were required or not. There were no systems of checks and maintenance and this led to a lack of identifying or actioning environmental risks to people in the service.

People and their relatives and loved ones told us they felt staffing levels were sufficient. People told us they had the support they felt they needed. However, people were not aware of the potential risks during the night or of the lack of oversight of the registered manager on how staff levels were identified and monitored.

Staff told us they felt there was enough staff to support service users safely. Leaders and staff had not identified what staffing levels were required to keep residents safe. Staff worked with people receiving regulated activity and also supported people with medicines and meals who also lived in the house but did not receive regulated activity.

Whilst we did not see anything through our visits to indicate there were not sufficient staff to meet people’s needs through the day. During our visit on 18 July 2024, we identified that there was one member of staff on the rota for the night. This member of staff was a ‘sleep in’ staff so were not expected to be awake. They ‘slept in’ a downstairs front room behind a fire door, with no system to alert them if anyone was up during the night. One person’s care plan indicated they would often get up in the night as they thought it was morning. This person was on the first floor of the home. There were no risk assessments or considerations as to how this person would be supported and kept safe during the night. The provider was unable to provide information on how they identified what staffing levels they needed to keep people safe. Following our visit in July the local authority had been supporting the provider to implement improved systems of governance and oversight, and additional night cover had been implemented. When we visited on 17 September 2024, the provider showed us a blank staffing dependency tool and we were told this had not been implemented, and the provider was still unable to demonstrate how staffing levels continued to be calculated. We observed safe practices had not been followed in relation to the employment of suitable staff. We reviewed 8 files and 5 were missing Disclosure and Barring Service (DBS) checks and references and employment gaps which had not been accounted for in the recruitment process. This did not provide assurances that consideration had been given to the suitability of staff that were employed.

Not all staff had completed mandatory training or competency checks. During the assessment period, we requested, and were provided with several different training records for staff which showed different levels of compliance. The leadership team could not confirm which was accurate therefore were not assured as to which staff were trained in what modules. Leaders could not evidence staff had suffiecient training in working with autistic people and people with a learning disability. This service was registered for caring for people with a learning disability as a primary need therefore it was important staff received this legally required training. As above, there was no process to ensure recruitment was undertaken in line with the Health and Social Care Act (Regulated Activities) Regulations 2014 Regulation 18 (Staffing) which specifies how staff should be safely recruited; and what processes should be in place to continually review staff numbers and competency.

Service users and relatives did not share any concerns regarding the infection control in the service. However, they were not aware of the risks from legionella or from unclean equipment.

The registered manager told us that the service was kept clean and that infection prevention and control (IPC) measures were in place. Staff understood their responsibilities to ensure areas were kept clean and hygienic, however this was not always displayed in the actions they took regarding IPC.

Infection prevention and control (IPC) was not always effective. We found communal towels in bathrooms, these are known to increase the risk of cross infection. We raised this with the registered manager on each of the 3 days we were on site, and for each of these days we found communal towels in use. Leaders had not completed or considered the need to complete a risk assessment for Legionella disease. The Health and Safety Executive national guidance states 'All systems require a risk assessment, but not all systems will require elaborate control measures'. We raised this with the registered manager after our first site visit who then stated they would ensure a risk assessment was completed. We requested evidence to confirm this which was not submitted. We also found broken panels and tiles in bathrooms together with poorly cleaned equipment, this increased the risk of cross infection.

There was a lack of systems, organisation and oversight to ensure all areas of IPC were maintained. There was an infection control policy however this did not provide details on how IPC risks were to be managed on a day to day basis. There was a lack of organisation and structure to IPC management.

People did not identify to us any problems with medicines and told us they got their medicines on time. However, people were not aware that medicines were managed unsafely which put them at risk.

Managers of the service told us all medicine related concerns found were due to the changeover to a new electronic system. However, we found that this was not fully accurate as the managers had conducted no audits of medicines for a significant length of time and therefore had no baseline for safe medicine management. Managers did not consider or understand the impact of poorly managed medicines or of the potential serious impact on peoples health and wellbeing.

Medicine management was unsafe. The medicine policies and procedures did not reflect the practice in the service regarding medicine management. There was no system in place to store or manage medicines including controlled drugs in line with regulation. We saw the medicines fridge, containing medicines, was out of temperature range as per national guidance at 11 degrees instead of between 2 and 8 degrees Celsius. Whilst monitoring instructions were included in a policy entitled ‘Medication Policy March 2024’, you told us no one monitored this and had no process for staff to escalate temperatures outside of range. There were two medicines policies one being in a paper format and the other in a digital format. These policies did not match and did not contain details of the types of medicines administered in the service including insulin for diabetes management and patches for pain management. The policy stated homely remedies were to be stored separately to prescribed medicines however we found them stored together. Homely medicines are an over-the-counter medicine used to treat minor ailments in a short-term manner. Medicines were disposed of in an open bin in the office, this was not in line with their own policies or procedures and was not reflective of safe practice. The manager secured an external pharmacist to provide support around medicines management given the risk identified. However, medicine management was still not safe by the time of our final site visit in September 2024.