Marcris House

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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

This assessment reviewed all eight quality statements in the safe key question. We found significant safety concerns and identified breaches of regulation in relation to people's safe care and treatment, how people are protected from abuse and improper treatment, safe staffing levels, effective staff training, safe environments, infection prevention and control and medicines optimisation. Some people did say they felt safe, but others gave examples where they did not. Our observations and findings showed people were at risk of neglect due to a lack of staff, staff awareness of peoples changing needs and poor staff training and support from leaders. When incidents happened, sufficient action to keep people safe and refer those to the external safeguarding team did not happen. There was not an open approach to learning lessons when things went wrong. Those risks were not reviewed when required, leaving people at further risk of harm. People were at risk of their health needs not being appropriately met as changing needs were not always identified. For example, pressure related skin damage, poor moving and handling, and nutritional support. External health professionals were not referred to in a timely manner. There was not enough staff deployed to support people with their needs. People said they would call for support and staff were not available to support them. The environment was not safely maintained, required extensive decoration and maintenance. Fire risks had not been assessed and people were at risk from those identified concerns. We found ongoing issues with cleanliness, infection risks and malodours through the home with risks to people accessing cleaning storage areas. Two people did not receive their prescribed medicine on the day of our visit because management systems did not identify it was missing. People did not receive their time specific medicine at the same time each day.

This service scored 28 (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 experience a culture of learning at the service and improvements had not been made in response to their feedback or untoward events they had experienced. They further told us they were not confident that concerns about their safety were listened to or who they could raise concerns with should they have any. One person told us, “[Another person] comes in my room a lot and picks things up. I shout and [they] leave. I’ve told the home, and they say it’s difficult because they can’t lock [them] up.” Another person told us, “If I had a concern, I have no idea who I would speak to.” The provider was asked to provide us with evidence where they had collaborated with people to review and learn from safety incidents and lessons that had been learned. However they were not able to provide that evidence. Safeguarding incidents had not been raised with the local authority or investigated by the registered manager. This meant people or their relatives were not part of the review process to improve safety and learn from significant safety incidents. These areas did not demonstrate to us that people experienced a proactive and positive culture of safety based on openness and honesty.

On the day of our visit, we could not speak at length to staff due to pressures on their time caused by a lack of staff on the shift. We attempted to seek feedback through telephone and email but found staff reluctant to share their views. Those staff we did receive feedback from could tell us about incidents or accidents that had occurred at the service. However, they could not explain the investigations and reviews of care that had occurred or learning that had been shared with them after these events. Staff could not explain occasions where they were provided opportunities to reflect on incidents and accidents through an open approach to lessons learned. Staff did not experience a proactive and positive culture committed to identifying, investigating, and learning from each safety incident. One member of staff told us, “Last month a resident fell with night shift before we came in, we were told in handover that they [explained injury sustained by person]. I did training for health and safety and manual handling. I know how to look after them.” They were unable to provide further information or detail as to the learning or any changes made following this event.

Systems were not in place to ensure learning through an open culture, enabling staff the opportunity to reflect on the care provided, learn and improve. For example via, safeguarding concerns, incidents, injuries or complaints. Learning therefore did not take place and the risk of harm to people was not reduced. Team meeting minutes did not reflect how staff/leaders were sharing learning or making improvements the standard of care. The provider did not identify this as an area of risk through their oversight and monitoring. Directors and the Nominated Individual (for the provider) were unaware of this significant number of unreported safeguarding concerns or incidents because their systems did not identify this as a risk. This placed people at risk of avoidable harm as there was a lack of oversight of incidents from the provider.

People gave limited feedback on their experiences on moving into the service and could not recall their involvement in the planning of their move. Most people were satisfied with the care they were now receiving however, one person gave a specific example where the continuity of care between services could have been improved in relation to equipment.

Staff were unable to explain any involvement they had when a person was admitted to the service. This was completed by the previous registered or deputy manager alone. They were aware of the involvement of other partner agencies at the service but told us the responsibility for interacting with partners fell to senior staff and leaders. Staff discussed an incident where one person was found with a bruise but were not aware of who or when a referral was made to healthcare professionals. We received feedback from visiting professionals that demonstrated staff and management were not aware of where to refer people when needed. This meant people may experience a delay being referred to the right professional and their health may further deteriorate.

Visiting professionals shared concerns about delays in seeking advice or escalating concerns. These included where people had been found to have fractures or pressure areas which needed treatment. This also include delays in getting the correct equipment in place to support people and the care they needed. Visiting professionals told us staff were not clear on the referral pathways and how to escalated. Another example was shared where staff made incorrect referrals for the needs of people, which further delayed support for their care. This included weight loss due to incorrect referrals for nutrition.

The provider did not have safe systems in place to ensure peoples safety was managed and monitored and they received a continuity of care. . Prior to this assessment we received some concerns from external health professionals. These included risks with skin integrity, lack of reporting incidents to the local authority and a lack of referrals to external health professionals. During the assessment, we identified that these risks were ongoing. People were not referred to the appropriate nutritional professional even though it had been identified one person had lost 10 kilograms of weight in four weeks. Other adults had also lost weight which had not been referred. The provider told us they had not identified the weight loss because they had not looked at the week on week trends. The provider could not evidence how they safely managed people’s transition between care services. The provider could not describe how they risk assess and develop appropriate mitigations to ensure people are kept safe as they move between services e.g., hospital passports, assessment, use of partnership working. This meant when people transferred between services, for example during a hospital admission, the necessary information may not be available resulting in delays receiving appropriate care.

Whilst people told us they felt safe at the service, examples of concerns which constituted potential abuse were shared with us. One person told us, “One of the [other] people here bullies me, I don’t know [their] name. I haven’t said anything because the carers don’t have time to listen or talk to me.” Another person showed us bruising to their arm and informed us it had been caused by another person living at the service. They had not informed staff of their injuries. Neither of these concerns had been identified by staff or leaders, nor reported as required. We referred these concerns to the local authority safeguarding team following our visit to the service.

Staff were unable to clearly describe safeguarding or the action they would take if they thought a person was at risk of harm or abuse. One member of staff told us, “Some have dementia, don’t know what they are doing after 5 mins. We manage, calmly, offer drink of water, offer what they want. Listen to them and answer back.” They were unclear as to their individual responsibilities to raise safeguarding concerns external to the service if needed. They told us, “Tell senior and if they forget, tell them again, and then tell my head one.” A second staff member said, "I did not feel safe here and felt like I could never be myself as I was never sure what reaction I’d receive. " The Nominated Individual said he was not aware of any of the significant concerns prior to the local authority visit. He says he knew that there was some gardening and maintenance required, but not the wider issues with safeguarding, investigating, reporting or safety. The NI and Director agree that systems have not been operated in Marcris House to keep people safe from harm. They say they have following a visit by the local authority identified safeguarding alerts that require reporting retrospectively and will complete these. They say that they have been unable to find the incident reports or safeguarding logs for those incidents reported to them by the LA, or other incidents that were not reportable. They told us that that lessons learned are not in place to support staff understanding and mitigate risks of future recurrence. The registered manager when in post did not demonstrate a good knowledge of when to report incidents of a safeguarding nature appropriately to keep people safe. However, the provider equally did not have the systems in place to identify these safeguarding concerns themselves, relying on third parties to identify those. This demonstrated to us from feedback from leaders of the organisation that systems were not in place to safeguard people

People were not kept safe from harm and concerns were not shared when risks to people were identified. We observed a number of people with minor injuries and bruises, that could not be explained. We reviewed people’s care notes, incident and accident reports and body maps in place and found these had not been recorded or reported appropriately. We could not be assured that these injuries, given their locations at wrists and lower legs had not been caused by moving and handling. Evidence could not be provided to show what actions the provider had taken to review these bruises and injuries. One person told us a mark had been caused by a person, possibly staff, tapping their wrist. They felt they could not report this. We reported this to the nominated individual and to the local authority safeguarding. We observed staff interactions with people and found that some staff were abrupt and terse in their communication with people. When providing care and support, some staff did not take the time to interact with people in a positive way and displayed a brusque, task focused approach. We saw that people at risk of falls were left for extended periods with no staff present. One person was known to have experienced repeated falls. This increased the risk of harm to people.

The was a lack of systems and processes in place meaning care was not always delivered safely. Monitoring of incidents was not in place to identify trends or analyse themes. Incidents were not reported within the service or to external professionals. The providers systems did not identify a significant number of unreported injuries. Safeguarding systems were not followed when incidents had happened. Incidents identified as potential safeguarding concerns had not been reported in a timely way. We asked for copies of the incident and Investigation reports identified prior to this assessment and as a result of our observations, which they provider told us had not been completed. We found some of the observed bruises and marks on people had not then been entered into the care record. Follow up actions had not always been taken and we found some incidents reoccurred resulting in injury. The provider had not identified through their own visits and checks that incidents were not reported, investigations were not carried out and safeguarding had not been reported. There was a culture among the staff team that did not question why some incidents were not reported appropriately to management, or to the local authority as required. This further demonstrated how the processes operated by the provider failed to identify culture within the service as a concern. Staff had received online training, but the provider could not provide additional evidence to demonstrate how safeguarding was discussed and knowledge checked with staff. The provider could not provide evidence of safeguarding audits completed by the registered manager, lessons learned from previous substantiated safeguarding outcomes, or how staff discussed and developed practise in response to safeguarding.

People told us they felt safe and were not exposed to risks, however they shared they felt more staff should be available to promote safety and to observe them. One person told us, “I do notice that we can be here in the lounge with no one watching over us. That doesn’t seem right. It could be 10 or 15 minutes, and anything could happen.” Another person told us, “It could be 15 minutes with no carer with us. I could go and find a carer if someone was in trouble I suppose, but it’s not meant to be like that.”

Staff we spoke with or received written feedback from confirmed they did not have involvement in the assessment of risks. However, they told us they knew how to work safely with people and mitigate risks by following care plans and guidance from senior staff. However, we identified examples where staff had not provided care that met people's needs. For example One person had also been laying in bed across two days and had been laying on their pressure ulcer. No one had repositioned them demonstrating that staff awareness of people was not sufficient. Staff were not aware of those assessed needs as they were not involved, meaning people were at risk of tissue damage, lack of support with continence, nutritional needs or reassurance when distressed among other areas. People experienced repeat falls and staff did not know how to mitigate the risks. People experienced weight loss across the service because people's dietary needs were not met and staff supporting them did not have the appropriate training. The provider told us that the registered manager completed all assessments and reviews and care records confirmed this as the registered manager had signed off all care plans.

We observed the majority of staff demonstrating a task focused approach. Staff would complete one task, such as assisting with washing and dressing. They would then move that person to the communal lounge, sit them in the chair watching the small television and move back to the next person on the list. When supporting people to safely transfer position or stand up to walk, there was a lack of supportive words or encouragement. We observed two occasions where poor manual handling techniques were used by staff. One occasion we saw a staff member pulling a person’s cardigan sleeve to encourage them to stand from their armchair. A second occasion we saw staff attempting to hoist a person in a confined area, which increases the chance of injury. Whilst we did not need to intervene, staff did not always use safe or best practise to support those people who were not being encouraged to be active participants when staff supported them to transfer. We saw risks were not always well managed which was due to a lack of oversight by leaders within the service and a lack of staff deployed effectively within the service. For example, some people were at risk of falls and had recently experienced falls and sustained an injury. Once people were moved to the communal lounge after personal care was provided, staff were not present to keep them safe if they tried to stand or mobilise.

The systems in place to keep people safe were not effective and people were placed at risk of harm. There were no systems in place to monitor mobility and falls. We discussed an incident with the provider around a third fall a person had recently resulting in injury. They were unable to provide us with an explanation as to why a referral was not made to health professionals or why the risk assessment was not updated until after the 3rd fall. We identified further examples where people’s needs were no reviewed following a change in their needs. Processes were not in place to monitor people for their safety. We saw at night there were no records to demonstrate people were positioned, monitored or observed as sometimes noted in the care plan. Processes were not in place to monitor weight loss. We checked the individual weights for people and saw a number of weight loss, cumulative over a period of months. The most significant being a significant amount of weight in a short period of time. The provider said they did not have a process to monitor the weights, leaving people at risk of harm through poor nutritional management. Systems did not ensure peoples changing needs were reassessed and appropriate measures put in place. We found 15 incidents that occurred prior to this assessment, resulting in some form of injury that did not trigger a review of those peoples care.

People told us they felt safe and comfortable living at the service. They felt their rooms were kept clean and had no concerns. However, this was in stark contrast with our observations which found overall that people did not have equipment that met their needs. We observed people’s rooms to be unclean, with tired and worn, broken furniture and furnishings along with poor standards of decoration and hygiene throughout. There were significant safety concerns regarding fire safety in the building.

Staff told us they were not aware of any risks in the environment. They raised no concerns when asked about equipment, cleanliness and the facilities in place. Considering our observations and recent feedback given to the service by visiting professionals, this demonstrated a complete lack of understanding and awareness. Specific to fire risks, when asked about training they had received, staff were unclear. One member of staff told us they had participated in a fire drill but not a practice evacuation. However, another member of staff told us, “(I did) fire training at beginning, when I started, [two years prior to our assessment] online training but no fire drill, not physical.” The nominated individual and director overseeing the home acknowledged the lack of maintenance and oversight of risks with the environment and equipment. They had ordered some equipment and begun repairs to the service. However there remained significant concerns with the safety of the building which we referred to the appropriate agencies.

We observed multiple concerns within the environment which posed a risk to the health and safety of people, visitors and staff. Cluttered storage areas which should have been locked, were open and accessible to people. Communal bathrooms and toilets were not clean, with evidence of long-standing dirt and debris present. Flooring was stained or sticky in many areas of the building. We experienced malodours throughout. We saw plants external to the building encroaching through people’s bedroom windows into their rooms, with window security devices showing evidence of rust and deterioration. We saw one window propped open in an unsafe manner, due to missing fixtures. This posed an entrapment risk to anyone placing their hand in the opening. On the day of our visit, the service was uncomfortably hot in temperature and people were visibly warm and sweating despite windows being open. We saw that people were being provided with frequent drinks, but no action was taken to improve the discomfort people were experiencing.

Processes operated by the provider did not keep people safe from harm from environmental risks such as poor maintenance and fire safety. Checks were not in place to ensure equipment was safe and used safely. For example, we found mattress overlays not secured meaning people could slip from the bed when seated. Hoists were not stored in hygienic areas, people did not all have the appropriate sling for hoisting. Pressure relieving equipment was not in place where required and when it was there were no checks or repositioning for people unable to do so. The provider asked if this was required. This left people at risk of deteriorating skin integrity and an increased risk of sores and wounds. Staff had not completed fire drills or required training. The fire audit completed found poor standards of fire precautions installed, for example fire doors, compartmentation, automatic fire detection and emergency lighting. The independent audit concluded that the areas of concern were mainly of a management nature. The provider received feedback from the local authority prior to our assessment about their observations, including lack of maintenance, malodours, fire safety concerns, broken fixtures and fitting, plants growing in the people’s rooms from outside, broken windows, accessibility issues. During the assessment, we identified that these risks were ongoing. Systems were not in place to effectively monitor the service meaning it had continued to deteriorate to a significant level without the providers knowledge. However, when they were made aware there has since been a lack of effective action to remedy these matters and make the service safe. We referred our findings to the fire protection officer and environmental health team who took action.

People consistently told us there were insufficient staff to meet their needs. Comments included, “I do ring my call bell, but I find they are often too busy, so I can wait up to 20 minutes before someone comes”, “I push the call bell, but they are so busy, so they sometimes say they’ll come back, but they forget”, “At night time the carers check on us after they’ve come on duty, but then there’s a big gap until they come to the room again” and “When they help me, they are so kind. It’s such a shame that they are focused on the job, with no time just to chat with us, that would make such a difference.”

Staff told us there were sufficient staff on duty but gave examples of when an increase would be beneficial. One staff member told us, “Yes there are enough (staff), to look after [people] nicely. Sometimes, if someone goes to a hospital appointment, we need another one.”

Staff were not seen to work together effectively to provide safe care that meets people’s individual needs. Staff were observed to be task focused, with no time to engage with people in social interaction. Staff told us they were provided with breaks throughout their shift however, we did not observe these being taken during our visit. We saw staff moving from task to task, and unable to respond promptly to people needing support at key times of the day. We also observed a number of occasions where people were unsupported when in communal areas and a lack of staff presence for those people who chose to remain in their rooms, particularly on the first floor. It was clear there were insufficient numbers of staff deployed considering the size and layout of the building and the level of support required by people.

Systems and processes in place did not ensure people were supported by sufficient numbers of staff deployed. Staff deployment at night was insufficient. The nominated individual told us that the registered manager used a dependency tool to assess people’s needs which indicated the number of care hours. We discussed this assessment which we found gave an inaccurate figure of care hours. The director supporting the home confirmed this adding it did not assess all areas of risk. The provider acknowledged this and put a sleep in staff member at night. However, this remained insufficient and was amended to three waking night staff, and later four when based on the current needs and risks to people at that time. The provider failed to ensure sufficient staff were on duty which led to the local authority taking emergency measures to deploy two staff over a weekend. The provider did not ensure that staff and the registered manager had sufficient training to carry out their role effectively or safely. People were at risk of poor care because training did not meet their needs. Training matrix shows that staff have not completed training in key areas such as falls management, skin integrity, pressure care. Staff employed in the kitchen were found to have no training as they covered from their caring role. The registered manager has not completed any management level training, all completed at the same level as care staff. Staff were recruited safely, we saw staff had undergone an interview, supplying a full checkable work record and undergone criminal records check prior to starting employment.

People told us they were happy with the measures in place to manage infection risks. However, as described under Safe Environments, this was in stark contrast with our observations. We observed a poor level of hygiene being maintained in the service which placed people at risk of exposure to infection.

Staff did not provide feedback about IPC. Leaders during discussions acknowledged the service was not adequately clean and hygienic. In response they said they brought in an additional cleaner on the weekend of 20 July 2024. The cleaner working in the home had little experience of the role having previously been employed as a career. Leaders acknowledged that the home required further maintenance and cleaning to ensure people were protected from the risks of infection or harm.

As described under Safe Environments, we observed multiple concerns in the environment which exposed people to the risk of infection due to poor standards of hygiene and cleanliness. We also observed signs of poor management of waste. Large waste bins at the front of the property were over filled and a large amount of discarded furniture, fixtures and waste were observed outside by a seating area. Staff told us that a group of feral cats lived in close proximity to the service. One of these cats was seen within the service, in a person’s bedroom, the dining area and a communal corridor. Staff confirmed this was a usual occurrence, with no awareness of the potential infection risks this presented. The director confirmed they would contact a local cat rescue service for their advice and support.

Processes were not in place to ensure the service was hygienically maintained. People were at risk of infection through a lack of cleaning and infection prevention and control. We looked at recent infection control audits. These did not identify concerns found in relation to the condition and cleanliness of the environment. For example we identified unclean surfaces which put vulnerable people with weakened immune systems at increased risk of the transmission of illness. Peoples bedding was stained and a malodour was present throughout the day of our assessment. The provider did not provide us with a copy of their policy in relation to infection prevention and control. The staff member responsible for cleaning had recently moved from the care team to the domestic team. They had not received training relevant to their new role. The audit completed by the previous registered manager and then assured by visits from the provider did not identify the significant cleanliness concerns found at this assessment. People were not supported to live in an environment that was clean and protected them from the risk of infection.

People told us they were happy with the support they received to receive their medicines. One person told us, “I get my medication on time; as you can see, [staff] are doing the rounds now. They are efficient.” Another person told us, “The senior carer does the rounds with the medicine and does it all correctly for me.” However, our observations did not support this positive feedback about people’s experience. We found that people did not receive their medicines in the organised and timely manner described to us by people. We observed significant delays to people receiving their medicines on the day of our visit. Medicine Administration Records (MARs) instructed administration times of 8am and 9am for morning medicines. We saw that the morning medicines ‘round’ was not completed until 11:30am. Prior to the assessment, we received some concerns from external health professionals. These included poor medicine management and ongoing late medicine rounds meaning people had insufficient time between doses and time critical medicines were not given as prescribed.

We did not receive feedback from staff about medicines. The provider acknowledged there were ongoing issues with the administration of medicines. They agreed that medicines were administered beyond 11:30am and started at 08:00am. They said they asked the senior why, and she said because she also was called away to carry out care related tasks. The provider was aware that this meant people did not receive their medicines in a timely way. They told us the registered manager changed the medicine cycle start day which had caused issues with delivery. As a result of this change, two people went without their medicines on the Monday. They said they were also audited by the local authority pharmacy lead which identified further improvements. They said this was in areas such as carers where not recording required information on medication administration records [MAR]. Medication storage was stored was not safe to ensure medicines remained within a safe temperature range. Although they installed air conditioning into the storage room, we found temperatures remained high. Overall, they said there was uncertainty about who leads on medicines management in the home. We asked for an action plan to address the numerous issues, but they did not have one in place. Before this assessment, we received concerns from external health professionals regarding these medicines’ issues. The provider was made aware of these, but they had yet to rectify those concerns. Feedback from the provider demonstrated they had failed to act robustly on concerns raised to them, and risks remained in place regarding medicines management.

People’s medicines were not managed safely. The medicines storage room was cluttered and disorganised. We found excess amounts of prescribed thickener and supplementary drinks along with prescribed creams, lotions with no organisation as to date of dispensing, opening or the expiry date. Medicine related paperwork was stored in crates, on the floor and shelves, with no filing system in place. Body maps were not used when applying transdermal patches to record the site they were applied and minimise skin irritation from repeated applications to the same area. Two people missed their medicines on the 22 July 2024 because the medicine stocks when received were not checked and entered into stock thoroughly. On the Monday morning at the new cycle, staff then realised, which was too late. We found a crate of erroneous medicines, some appearing to be discontinued or no longer required, with no obvious reason for remaining at the service and not being returned to the pharmacy for safe disposal. Due to a lack of staffing, one senior completed the medicine round which took them 3 1/2 hours. We confirmed with the provider 5 people who required their medicines to be given as time critical and could not be assured these were given at the correct time. This means those peoples medicines were not administered as the prescriber intended and their medicine may be less effective. Medicines for all people were then again administered for lunch at 12:30pm meaning insufficient time between doses meaning the effectiveness of the medicine may be compromised. There was no homely policy in place and people were administered given homely medicines without GP sign off. There were no ‘As required’ protocols in place to guide staff how to administer medicines to people who may be unable to communicate their wishes or discomfort. This meant people who may require these medicines would not have those administer for a variety of pain and other needs.