Marsh Farm Manor 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

We reviewed all of the quality statements in this key question.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Incidents and accidents were recorded and discussed in meetings and handovers. Any immediate responses were recorded, and themes or trends identified. The provider also had oversight of all incidents and accidents so they could also monitor patterns across all of their services. The registered manager told us as the service was new they were always looking to see if they could develop systems and processes following any incidents

People told us when things went wrong staff responded safely. People felt able to raise any concerns with staff if they were worried about any aspect of their care.

The registered manager reviewed incidents monthly and told us there were systems to learn from any events. The registered manager told us they were open to learning and making sure any improvements identified were actioned where possible.

Feedback shared by the provider from visiting healthcare professionals did not raise any concerns for this quality statement.

There were systems to make sure people’s needs were known before people moved in. There was a detailed hospital passport available for staff to share with healthcare professionals in any event of a visit to hospitals. This included details of GP appointments and healthcare advice received. This made sure healthcare staff were fully aware of people’s care and treatment prior to any admissions. When people moved into the service staff completed a ’48 hour’ care plan audit which prompted staff to make sure they had all the information needed for people’s care.

People talked to us about moving into the service. Whilst some shared the decision to move in was difficult, they felt staff had made them feel welcome. One person told us, “I have settled in really well. The first couple of days were strange, but then everything clicked, and I am now sleeping very well.”

The registered manager told us they made sure pre-admission assessments were completed prior to people moving in. If people were in hospital, then assessments could be completed with people on the ward and with hospital staff. The assessment might be completed by other senior managers but was always discussed with the registered manager prior to any agreements. Staff told us they liaised with any healthcare professionals involved in people’s care, so they had a good understanding of people’s healthcare needs.

The provider had a safeguarding policy which was available to staff. Any incidents of concern were logged and had been shared with the local authority safeguarding team. Actions had been taken by management to keep people safe. Staff had applied to the local authority for DoLS authorisations, but at the time of our assessment they had not been assessed.

Staff had received training on safeguarding and knew how to report any concerns. The registered manager told us there was information available to people on keeping safe on various notice boards at the service and given out in formal documents. They also told us safeguarding would be discussed at ‘residents meetings’ to give people the opportunity to talk about keeping safe.

People we spoke with told us they felt safe at the service. People felt able to raise concerns and knew who the registered manager was. People told us they felt the registered manager was very approachable. One person told us, “I feel very safe, there are safety gates and codes, you feel secure, and you feel safe.”

We observed people were supported safely by staff. Information on safeguarding was available on notice boards at the service.

Staff knew where risk assessments were kept, and they could access them anytime. Team leaders told us they were involved in reviewing risk and updating records in a timely way. One member of staff told us, “We do risk assessments and review them when people come in, after 48 hours and 72 hours. The electronic system then reminds us we need to update them. If people have a fall, we review the risk assessments. We might also contact healthcare professionals if needed or phone out of hours on call support.”

People told us they were supported by staff safely to manage any risks. People felt they had the equipment they needed to reduce any risk of harm.

We observed people being supported safely by staff who knew them well. We saw staff were following people’s risk management plans when providing care and support.

People had risk management plans in place which were being reviewed monthly or sooner if people’s needs changed. We found 3 risk management plans which required further details. The registered manager took action during the assessment to amend the plans adding in more detailed guidance for staff. Where people required monitoring to help manage risks, staff kept records of actions taken. For example, where people needed to be re-positioned due to concerns about their skin integrity, records demonstrated staff were following people’s care plans.

People told us they were pleased with the environment and all the equipment in their rooms worked well.

The service was newly opened, so the environment was very well maintained.

Staff told us they felt the environment was safe and helped to keep people free from harm. For example, staff told us areas of the home that could be a risk to people’s safety were behind locked doors. Door alarms were being used to help staff identify when people may be accessing areas of risk, for example the stairs.

Safety checks on various pieces of equipment and the environment were taking place. This included weekly fire checks and checks of equipment such as beds and wheelchairs. The provider organised external contractors to carry out any servicing checks.

The provider used a dependency tool to calculate staffing numbers. We observed there were enough staff available to meet people’s needs. No agency staff were being used at the time of our assessment. Staff had the required pre-employment checks carried out prior to starting work. The provider had systems to make sure staff had an induction, ongoing training and supervisions. As the service had only been open for 3 months the registered manager had not started the appraisal process for staff.

People and relatives told us they thought there were enough staff available to meet their needs. One relative said, “I think that there are enough staff. The Manager has a good plan, to get the right number of staff in the future to match the increasing number of residents. I admire that they are taking it gently and training staff properly without rushing.” People knew how to use their call bells and did not share with us any concerns about waiting for staff to respond. People felt the staff had the training they needed to work safely.

Staff told us there were enough of them to work safely. The registered manager told us they reviewed staffing numbers monthly or more if needed and would increase staff if needed. For example, during our assessment a review of night staff numbers was taking place. The registered manager told us numbers would be increased in response to people’s needs.

There were enough staff available to support people safely. We observed staff from different departments working together as a team to meet people’s needs.

We observed the environment was kept clean and staff were seen to be following good practice guidelines. For example, we observed staff washing their hands appropriately and wearing personal protective equipment when needed.

Staff told us they had been provided with the training they needed on infection prevention and control. Staff also told us they had supplies of chemicals and all the equipment they needed to keep the service clean.

There were cleaning schedules which recorded all cleaning taking place and the provider carried out infection prevention and control audits. Staff received training on infection prevention and control and other related topics such as food hygiene. The kitchen had achieved a ‘5’ rating in November 2023 following a visit by local environmental health teams.

People we spoke with told us they were happy with the standards of cleanliness in communal areas and in their own rooms. One person said, “It is lovely, they keep it spotless. Everything works here, it is brand new.”

People had their own medicines administration record where staff recorded all medicines administered. There were no gaps in recording found. Staff had medicines training before being checked for competence. Where medicines errors occurred, we found clear records were kept of actions taken and who had been involved. Regular medicines audits had taken place which helped identify minor actions for improvements.

The registered manager told us they were looking forward to having an electronic medicines management system in the near future. They told us whilst they felt systems to manage medicines worked well, an electronic system would help to reduce medicines errors and mitigate risks.

People were supported to manage their own medicines where possible, if this was not appropriate medicines were managed by staff. People told us they felt their medicines were managed well by the staff team. Comments from people included, “Everything to do with my meds goes okay” and “I do take medicine, I am not medical but they [staff] wrote them all down and they know exactly what I need to take.”