Maranello Also known as Zero Three Care Homes LLP

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

The managers had not ensured there was a culture in which staff felt valued and protected people's rights. Managers were not always visible in the service. Staff were able to raise concerns but did not feel their voices were heard or receive the support they needed. The service did not have effective governance processes to monitor the quality and safety of the service and lacked systems to support learning and improvement. The service did not always share information with other organisations as required. The provider had not ensured staff were protected from abuse at work. They had not taken appropriate action in response to concerns raised relating to victimisation.

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.

Staff did not feel there was a listening culture within the service to promote learning and improvement. Whilst they felt able to raise concerns, staff told us these were not acted upon. A member of staff said, “[Managers] are just not addressing it, not taking it to the next level of what to do. They do not get the experience of what is going on.” However, there had been a recent change in managers at the service and staff felt overall this was a positive change. The provider told us they had a crisis management plan which included support from other managers in the organisation to make changes to improve the service. However, this had been implemented in October 2023 and feedback from staff suggested this had not been effective.

The provider had not set a culture which valued learning and improvement. Staff did not feel supported by managers to maintain a positive improvement-driven culture. The provider had not ensured staff used the least restrictive options when supporting people. Records we reviewed suggested there was a culture of imposing blanket restrictions on people. For example, staff meeting minutes stated staff should offer people 2 snacks per day, not crisps or chocolate. This indicated a culture of control and not informed choice.

Staff feedback was mixed regarding the visibility of managers within the home. Although managers were present in the home, some staff felt they were not actively present when they required support, particularly when incidents occurred. A member of staff said, “The [managers] will not come and help.” However, other staff felt they could start to approach the new manager with their concerns.

The service did not have effective processes to identify and act on issues which affected people’s care and had a detrimental impact on staff. The provider had completed a staff survey; this covered the region, not individual services. Whilst themes had been identified and an action plan created feedback from staff suggested the issues remained.

Staff did not feel confident their voices were heard. They had provided feedback about the service and gave examples where they had spoken up in the past to senior leaders about their concerns and had not had a response. A staff member told us, “I sometimes feel listened to, but I do not feel like it’s the best.” A second member of staff said they had raised their concerns and were told the issue was being forwarded to head of quality but had not heard anything further.

The provider had started to introduce freedom to speak up guardians. This was in its infancy, and we did not see evidence it had been effective. Examples of concerns staff had raised, including insufficient training, unsuitable environment etc remained an issue during our visit. The service had not always been open and honest with people if something went wrong in a timely way. We were told by more than one person’s relatives they were not informed when an incident occurred until they contacted the service about an unrelated matter.

The provider had not ensured staff were protected from abuse at work. Staff had been harmed and felt the provider had not always responded appropriately or offered the required support.

The service had not always followed their equality, diversity and human rights policy. Staff told us they had raised concerns relating to staff and people being targeted but felt the provider had not taken appropriate action.

Feedback from staff indicated managers had not recognised the impact of incidents in the service. Managers confirmed they were not aware of the extent of some issues until our assessment. Managers had not always completed audits and where they had the identified actions were not always completed. This included cases where abuse had been identified but not reported or acted upon.

The service’s governance processes were not always effective to monitor the quality of the service. Risks to people had not always been identified which meant there were not mitigations to safeguard them from abuse, accidents and incidents. Managers had not ensured staff had the appropriate knowledge and competence for all aspects of their role. Whilst the provider was introducing new training to support staff, some staff had to wait months for this. This meant people remained at risk. The service was not always open and honest about concerns within the home. Where safeguarding concerns had been identified, the relevant organisations were not informed. For example, notifications had not been submitted to CQC for recent registered manager changes and a serious injury; where notifications were made, they lacked detail and had to be re-submitted. The provider had not monitored the use of restraint and restrictions to people. When staff used restraint, this was not appropriately documented and reported to the appropriate body.

Relatives we spoke with told us the service worked well with other professionals to ensure their family members received the right support to meet their needs.

The service linked with the GP for Multidisciplinary Meetings (MDT). These were held for all people living at the service every 6 months.

We did not receive any feedback about partnership and communities from partners.

The provider did not always submit notifications to CQC. Following our assessment these were being done, but there was room for improvement in the quality; some had to be returned for further detail to be included. The provider did not have effective engagement with people’s families. They received only 1 response to a questionnaire, and no families of people living at Maranello attended a family audit meeting.

Staff told us they did not always have the opportunity review learning from incidents. A member of staff said, “I would not say it is safe, when it happens it is the last place you want to work to. You do not get debriefing. It not very safe.”

The service lacked systems to support learning and improvement. Records we reviewed did not show clear investigations into incidents. This meant there were missed opportunities for learning to be shared with staff and improvements to be embedded. There was a service improvement plan which included an action for managers to review incidents to identify trends, shown as completed. However, as we found not all incidents had been identified and logged, this would not indicate a true reflection of themes in the service. Other actions in the plan due for completion by February 2024 remained outstanding at the time of our assessment.