Mariantonia House Residential Care Home

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 the management and governance promoted and assured high quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. We found that there were aspects of a culture that did not reflect a culture of openness or transparency. There were no systems of management or governance to ensure care was safe or being delivered in line with regulation. Where support was given from outside agencies the improvements implemented were not sufficient to provide adequate assurance that service users were safe.

This service scored 39 (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 and staff told that the service was run with the interests of the people at the heart of what they did. However we found examples where people's rights had not been upheld for example where staff and managers had used language to describe people which was not in line with equality and diversity national standards.

There was no clear vision, aspiration or direction for the service. There was a culture where not having to thoroughly evidence how people’s monies were spent and staff did not take responsibility or accountability for ensuring people were protected from abuse. The provider was unable to share a statement of purpose. A statement of purpose provides information on the aims and objectives of the service, this is a formal requirement under the Health and Social Care Act 2008, Regulation 12, schedule 3. The provider had not implemented effective systems of governance and there were no aims to develop and maximise people’s potential. There was a culture where managers did not take responsibility or accountability for ensuring people were protected from abuse. Staff were not sufficiently trained to identify risk factors for abuse which resulted in a lack of transparency when abuse indicators were found on inspection; for example signs of financial abuse.

Whilst managers and staff told us that managers were capable and compassionate; we found significant evidence which showed managers were not capable of running the service openly and with transparency or in a way which supported clear oversight. The registered manager had not complied with several conditions of their registration such as regulation 18 of CQC (Registration) Regulations 2009 to notify us when certain incidents had occurred, reg 12 of CQC (Registration) Regulations 2009 regarding the statement of purpose or regulation 19 and schedule 3 of the Health and Social Care Act 2008 regarding safe recruitment. The registered manager was not aware of the need to submit notifications and in general showed very little awareness of their legal responsibilities.

The provider who was also the registered manager had failed to adopt systems of governance to ensure people were kept safe. The provider had not identified the issues we found during the inspection and failed to make adequate improvement when support had been offered by the local authority and also by pharmacy to improve the systems in the service. There continued to be concerns around the understanding and application of safe medicines management, and policies and procedures had not been implemented or considered in relation to safeguarding. Language used in applications to other professionals did not demonstrate an approach that was compassionate to people’s needs. There had been no clear recruitment processes, and this had resulted in people being employed without the necessary checks to ensure they were suitable to work with vulnerable people.

Staff told us they knew how to whistleblow and would if they had concerns about any abuse. However, the service did not have a structure which allowed staff to raise concerns confidentially about any managers if they had concerns over manager behaviour. Staff felt the registered manager was approachable and that they would be supported to speak up about poor care.

There was a safeguarding procedure which had been implemented since we first visited in July 2024 and this included information for staff on whistleblowing. We could see signatures indicating staff had read the policy, however we were not assured that these policies and procedures had been embedded in the service. There were no systems or processes to promote service users voices and the language and terminology did not promote people's abilities to have any concerns taken seriously.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff we spoke with felt the service was well run and managed. However, staff were not aware of the need for audits, quality assurance or risk management processes. The staff were not aware of any methods to improve care or people's health outcomes. Staff were not aware of legally required mandatory training requirements they should have completed such as the Oliver MacGowan training package to better support people with a learning disability or autistic people.

There were no processes to ensure that lessons were learnt, and improvements made. There was no oversight of accidents and incidents, and management of safeguarding concerns did not take steps in line with their policies or procedures or in line with the expectations from the local authority and CQC. Audits and checks were not taking place in the service and there was no mechanism for the provider to identify issues or concerns in the service. There was no consideration of the safety of people in the event of a fire and actions taken to address these issues was under the direction of the relevant authorities. There was no oversight of risks to people's safety and no application or oversight of current best practice in the service. This was a breach of regulation 17 (Good governance) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as there was a lack of accountability, knowledge and management oversight.

The registered manager told us they realised that there was a lack of effective systems to ensure that they learnt and improved from concerns or incidents. The registered manager told us they were open to support from partner agencies, for example the local authority to assist them in improving their systems of oversight and governance.

There were no systems or processes to ensure that lessons were learnt. Between our first visit in July 2024 and our third visit in September 2024, the local authority and the local pharmacy had supported the registered manager to access and implement systems of oversight and governance to improve the outcomes for people. However, the scale of improvement has not been sufficient and people remain at serious risk of abuse and poor care.