CQC report explained · a nursing home
What the CQC found at Martlet Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks were not consistently managed. Medicines and cleaning products were not always stored securely, and one person at high risk of choking was not noticed when they appeared to be choking.
- Effective?
- Good
- Assessments and care plans were detailed and personalised. People were supported to access healthcare, eat and drink enough, and receive suitable diets.
- Caring?
- Requires improvement
- People often described staff as kind and caring, but privacy and dignity were not consistently protected. Staff did not always notice soiled clothing or speak discreetly about personal care.
- Responsive?
- Requires improvement
- Care plans reflected people's needs and preferences, and activities helped people maintain relationships. However, some complaints and concerns were not followed up consistently.
- Well-led?
- Requires improvement
- Quality checks had not identified important safety and dignity problems. The manager had taken some immediate action and was recruiting staff, but oversight was not yet reliable.
What inspectors found, April 2023
Rated Requires Improvement; inspectors found risks to safety, privacy and dignity, despite good care planning, healthcare support and activities.
This was the home's first inspection. It was unannounced and took place on 13 February 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care, staffing and management records.
Inspectors found serious shortfalls in some areas. Medicines and cleaning products were not always stored safely. Staff did not always recognise risks, protect privacy or respond to people's needs. Agency staffing and new staff who did not know people well added to these problems.
There were also positive findings. Care plans were detailed and personalised. People were supported with healthcare, food, drink and activities. Many people described staff as kind and caring, and said they were happy living at the home.
The overall rating was Requires Improvement. Safe, Caring, Responsive and Well-led were all rated Requires Improvement. Effective was rated Good. The provider had to take action after breaches of regulations, and CQC said it would monitor progress.
Personalised care planning
Care plans were comprehensive and reflected people's different needs, preferences and changes in condition.
“Care plans were comprehensive and reflected people's diverse needs and preferences.” from the report
Healthcare support
Staff worked with health professionals and helped people attend a range of appointments. Records showed collaborative care for wounds and other health needs.
“Staff worked effectively with other agencies to ensure people received the support they needed.” from the report
Food and hydration
People had drinks and snacks available, could choose between food options, and received special diets where needed.
“People were supported to have enough to eat and drink.” from the report
Activities and friendships
People had opportunities to join activities, develop friendships and avoid social isolation. Some people valued mindfulness and other wellbeing sessions.
“There was an effective system in place to help people to avoid social isolation and support them with activities that were relevant for them.” from the report
Kind staff relationships
Many people spoke positively about staff and said they were kind and caring. Inspectors also saw some compassionate and attentive support.
“People spoke positively about the staff and described them as kind and caring.” from the report
Unsafe risk management
seriousMedicines and hazardous cleaning products were left unsecured. Inspectors also found that staff failed to notice when a person at high risk of choking appeared to be choking.
“Risks to people were not being consistently managed, this put people at an increased risk of harm.” from the report
Privacy and dignity
seriousPeople were exposed to risks to their dignity during building work and when staff discussed personal care or medicines in front of others. Laundry problems also left some people without their own clothes.
“People's privacy and dignity were not consistently protected.” from the report
Reliance on agency staff
needs fixingThe home relied heavily on agency staff, and some new staff did not know people's needs well. This affected the consistency of care and how quickly people received support.
“There was a heavy reliance on agency staff to maintain staffing levels.” from the report
Late medicines
needs fixingMedicine rounds could take a long time. Some people said they had waited for pain relief, and staff said breakfast medicines were sometimes given in mid-morning.
“Some people told us they had to wait longer than they would want for their medicines.” from the report
Complaints follow-up
needs fixingSome people and relatives said their concerns had not been answered or thoroughly investigated. CQC recommended reviewing how complaints sent by email were managed.
“Complaints and concerns were not always responded to in a consistent way.” from the report
Weak quality checks
seriousThe home's monitoring systems did not identify important safety, dignity and building-work risks. This was linked to a breach of the good governance regulation.
“Systems for monitoring risks and quality of the service were not consistent.” from the report
- 01What has been done to keep medicine storage rooms locked and attended, and how are medicine rounds now kept on time?
- 02How do you check that cleaning products are locked away and that people at risk of choking receive the right support at meals?
- 03How do you protect people's privacy and dignity during building work, personal care and medicine administration?
- 04How many permanent staff are now in post, and how are agency and new staff shown each person's needs and evacuation arrangements?
- 05How are complaints made by email recorded, investigated and answered?
This was an unannounced first inspection covering all five key questions and infection prevention and control; no nursing care was being provided at the time. This explanation was written from the published report of 13 April 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Martlet Manor
Each visit the CQC has published, newest first, back to the day the home was registered.
- April 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2021
Registered with the Care Quality Commission on 14 October 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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28 live-in carers within about an hour of West Sussex
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,170 a week. 23 can care for a couple. 11 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.