Marina View Care Home

We found 2 breaches of the legal regulations.

People were not always supported to take their medicines safely. Staff were not always recruited safely which left people at risk of harm.

People's risks and needs were not always assessed adequately, and we have included this as a breach in the well-led section of the report.

There were some gaps in the maintenance records for the home.

Although there were safeguarding processes in place, there were a high number of safeguarding alerts.

However, health and safety checks had been made, and the environment was clean and comfortable. People were protected from the risk of mistakes as improvements had started to be made in processes and staff knowledge.

Staff considered consent throughout their care interventions and we saw Mental Capacity Act assessments in people's records. The manager made applications to the local authority to legally deprive someone of their liberty where appropriate. The manager used tools to monitor people's outcomes. Systems were in place to make sure people were supported to eat and drink healthily.

However, people were left at risk of harm as there were gaps in care plans and risk assessments. Staff did not communicate well with external services, or provide support to make sure people lived healthier lives.

People were treated with kindness, dignity and compassion. Staff treated people as individuals and promoted people's choice and control.

Permanent staff could respond to people's needs.

The service had policies to support the wellbeing of staff.

People were not always supported to participate in leisure activities. People told us that the service did not always understand their wider needs, or provide appropriate information. We found improvements were required in relation to end of life care.

However, there was a complaints policy and manager monitored compliments and complaints.

We found a breach of the legal regulation.

The service had several managers since opening in October 2023 and the service has been without a manager who is registered with the CQC, which is their legal responsibility. This had a direct influence on the governance of the service. At provider level, there was a clear governance structure, although we found the provider was slow to arrange additional support to address concerns such as the high number of safeguarding alerts and medicines errors.

We found that systems were not in place to make sure that pre-admission assessments, risk assessments and care plans contained sufficient and up to date information to guide staff about how to care for people. Systems to monitor the service were managed on an adhoc basis. Managers were not always clear about their legal responsibilities.

However, staff told us they felt that new management arrangements were positive, and they felt able to speak up.