Maranello Also known as Zero Three Care Homes LLP

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

The service did not always manage incidents affecting people’s safety well. Managers had not ensured lessons learned were identified and shared with staff to keep them and people safe. The service worked with partner agencies when people were admitted to the service. However, they had not fully considered the compatibility of people living together. Staff knew how to recognise and report abuse but felt they were not listened to by managers and appropriate action was not always taken. Staff described occasions where people were put at risk due to physical interventions made without authorisation or training. People’s risk assessments did not always include enough guidance for staff to mitigate risks to people or rationale for restrictions. We found examples of blanket restrictions and where the least restrictive options were not taken. People were provided with care in a well-maintained environment. However, staff did not feel safe; they did not have sufficient training to meet people’s needs and prevent incidents and felt there was not always enough staff with the right skills to meet people’s needs. The service used effective infection, prevention and control measures to keep people safe from infection. Staff followed systems and processes to prescribe, administer, record and store medicines safely.

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.

We received mixed feedback from relatives about staff learning from incidents. Some relatives reported a decrease in incidents as staff learned and responded to people’s needs well. A relative said, “I feel staff know [person] well and have learned how to support [them].” However, other relatives felt staff had not been trained to meet their family members’ needs and did not use incidents to learn and change how they supported them. A relative said, “They don't have the skills to support [person] well. [Person] needs structure and something to do that [they are] interested in. [They need] space when [they] get upset. Staff don't understand these things about [person].”

Staff did not always feel listened to when they raised safety concerns. They told us they provided feedback about support they required, and felt the new training offered was either not fit for purpose or not coming soon enough to help keep them and people safe. This meant people and staff remained at risk. Staff made comments such as, “We have [name of training]. It is not adequate.” And, “I do not think [name of training] really works and they are changing to [different training], but I don’t know if that will work. We need more.” And, “I feel we are not listened to and I am just a support worker.”

The service did not have a proactive approach to investigating and learning from incidents and there was lack of prompt reporting to external organisations. Where incidents occurred, managers had not ensured lessons learnt were shared with staff with clear actions embedded in the service. This meant there was a risk incidents would continue to occur. For example, following an incident prior to the assessment visit relating to harmful substances, we found appropriate action had not been taken to reduce the risk of the incident reoccurring.

Most relatives told us they felt the service liaised well with other organisations involved in their family member’s care and information was shared. A relative said, “I think they do work with other professionals and services and yes, they will get their advice on things and share things as needed.”

The provider had not fully considered the compatibility of the people living together and as a result individuals were involved in incidents where they were physically assaulted by other individuals. A member of staff said, “I would not say they love living together, they tolerate living together. They are frightened.”

Partners did not provide any feedback in relation to safe systems, pathways and transitions.

The provider gave examples of working with other professionals. This included regular multi-disciplinary meetings.

Relatives had mixed views about whether people were safe. Whilst some relatives said incidents of distress had reduced, others had significant concerns staff did not take appropriate action to keep people safe. They felt safeguarding issues had not been managed well. A relative said, “I never hear what is happening and I have no idea if a safeguarding was raised. I only found out when I visited…it seems you never get any info on anything unless you ask.”

Staff said people did not always feel safe. They told us, “Some service users do not feel safe.” And “No one wants to be in fear – [person] covers [their] ears as [they are] uncomfortable, and [other person] does not come out of [their] room. “ Staff understood their roles in relation to safeguarding and gave examples of where they had raised safeguarding concerns. However, they told us action was not always taken in response and they felt they were working in an unsafe environment. A staff member said, “I do not think it is safe here.” Staff described occasions where they physically intervened outside of best practice and lawful guidance. Staff did not have the required training or authorisation to do this, and it could have put the person at significant risk of harm.

People appeared relaxed and comfortable in the presence of staff. We observed staff engage warmly and appropriately with them. However, we saw a person in their room appeared withdrawn and staff stood outside their room without engaging with them. Whilst this was in line with their positive behaviour support plan, the plan also stated for the person to have frequent interaction throughout the day, and we did not see evidence of this. Therefore, we were concerned the person was at risk of social isolation.

The provider failed to ensure people were supported safely. We found people were not supported with their positive behaviour support plans and a lack of guidance for staff to mitigate risks to people’s mental health. The service’s process was not robust to identify all safeguarding concerns or educate staff and people to understand people’s rights. Where incidents of restraint were used, or physical harm was caused to a person these were not always investigated or reported to the appropriate organisations. We saw team meeting minutes which indicated all staff could provide support during incidents trained or untrained. People’s care records suggested a blanket approach to restricting people without Deprivation of Liberty Safeguards (DOLS) authorisation and no evidence alternative strategies were attempted.

Relatives did not always feel involved in managing risks to people. Whilst some relatives felt listened to, 1 said they did not feel their knowledge was used to inform how staff supported the person and another told us they felt risks were managed in an overly restrictive way. A relative said, “I don’t like the door locking. I’m quite uncomfortable with it.” We were also told relatives were not always informed when incidents occurred or when restrictive practice or restraint was used.

Staff gave examples where risk management was ineffective, putting people and staff at risk. Staff described multiple incidents which had a negative impact on them or people. However, during our visit staff described people’s needs and were aware of potential triggers for a person; they shared this with the inspector to ensure their presence did not cause the person distress.

People’s access was restricted in most areas. During our visit, we found all bedrooms and doors leading to the kitchen and laundry areas were locked as well as numerous cupboards and drawers. Staff said bedrooms were locked to prevent people entering other people’s bedrooms which may cause distress; they had not considered the distress caused when people were unable to access their own rooms. The cleaning cupboard was left open. This meant there was a risk people could access hazardous substances.

People’s risk assessments did not detail how to mitigate them. People’s risk assessments did not include rationale for restrictive practice. A person had restricted access to the kitchen and use of equipment; it was unclear from their record whether they had a history of putting themselves at risk. Staff did not follow the correct risk assessments and Positive Behaviour Plans (PBS) to support people. This resulted in incidents which put staff and people at harm. For example, a person’s care plans and risk assessments identified they needed to go out and engage in activities during the day to reduce incidents occurring. We reviewed daily records for 1 week which showed the person left the house once and lacked evidence of activities. The provider had not reviewed restrictions to people. This meant people were not empowered to make their own decisions and live in a home where they were not restricted.

Most relatives felt the environment was safe, suitable and well maintained, although sometimes repairs and replacements were not resolved promptly.

Staff did not feel safe in the working environment. They told us they had requested more training because they felt the training provided had not given them the required skills to keep themselves and people safe.

People’s care was provided in an environment which was mostly well maintained with some improvement work ongoing. Some people’s bedrooms were personalised, others were quite sparse, as was the communal area; it was unclear whether this was by choice. The communal areas included posters which could have been in staff areas to avoid an institutional appearance.

Staff completed health and safety checks. However, we were not assured these were robust. During our visit, we found a risk remained following a recent incident. This meant adequate action was not taken to reduce the risk.

Most relatives we spoke with told us there were enough staff who were trained and met their family member’s needs well.

Staff told us they did not have sufficient training for their role. They also said more staff were needed with the right skills to support people safely. They said there were times during the day, particularly in the early mornings where there were insufficient staff to provide the support people needed to stay safe. They told us staff morale was very low and as a result many staff were leaving. This meant the service was relying on agency staff who did not have sufficient training to support people effectively, especially when incidents occurred. The provider told us they had ensured enough staff were deployed in shift, including more than the funded levels before the inspection.

People were supported by enough staff during our visit. We observed positive interactions between people and staff who appeared to know them well.

Managers had not ensured staff received appropriate training for their role or planned rotas to ensure there was an appropriate skill mix among staff. This meant people were not receiving consistently safe, good quality care to meet their needs. Staff recruitment processes included Disclosure and Barring Service (DBS) checks which provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. However, staff files we reviewed did not include full employment history.

Most relatives said the service was clean and risk of infection was well managed. A relative said, “It is generally kept clean and tidy - occasionally standards will slip a bit, but on the whole fine.”

Staff did not have any concerns relating to Infection Prevention and Control (IPC).

Staff we observed demonstrated good IPC practices. The service was clean and fresh. Laundry was managed appropriately to reduce any risk of infection and kitchen areas were clean and tidy.

Staff completed audits to monitor IPC practice and identified actions. People’s records included information to give staff guidance to ensure people were safe from infection.

Most relatives were happy with how their family member’s medicines were managed and felt they were kept informed of any changes.

Staff took appropriate action when it was identified a controlled drug tablet was missing.

People’s medicines were managed safely. Their records included details of any allergies and how they wished to take their medicines. There were protocols to give guidance for staff on when to administer PRN medicines, which are medicines taken as and when required.