CQC report explained · a nursing home
What the CQC found at The Martlets
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2021
Rated Requires Improvement; inspectors found major progress in safety, but concerns remained about mental capacity law and management systems.
This was an unannounced, focused inspection on 8 April 2021. Inspectors spoke with people living at the home, staff, relatives and healthcare professionals. They reviewed care records, medicines records, staff files and management records.
The home had made significant improvements since its previous inspection. Inspectors rated Safe as Good. Risks, medicines, staffing, training, infection control and incident reporting had improved. People generally said they felt safe and were treated kindly.
The home was still rated Requires Improvement overall. Inspectors found that the Mental Capacity Act was not always followed properly. Some records did not clearly show whether legal conditions were being met. The management team had improved its checks, but needed more time to show that improvements would last.
Safer care
Risks to people's health were assessed and reviewed more reliably. Staff had improved training to recognise deterioration and seek professional advice.
“At this inspection, the provider had made significant improvements to ensure the risks to people's health were appropriately managed.” from the report
Staff skills
New and agency staff received induction, training and competency checks before supporting people. Staff also received regular supervision.
“Staff received a comprehensive induction and were assessed as competent before they could support people.” from the report
Kind and person-centred culture
People were treated with kindness and respect. Inspectors saw people taking part in activities that supported their emotional and social wellbeing.
“The culture of the service was positive, person-centred and promoted good outcomes for people.” from the report
Infection control
Inspectors found suitable measures for visits, testing, protective equipment, social distancing and cleaning during the COVID-19 pandemic.
“The home was clean, hygienic and maintained to a high standard.” from the report
Mental capacity records
needs fixingRecords did not always make clear whether Deprivation of Liberty Safeguards conditions were being followed. Mental capacity assessments were not always easy to find, although the manager later gave assurances that they had been located.
“It was difficult to ascertain from peoples care records whether the conditions were being met.” from the report
Complex care records
needs fixingInformation was kept in several places, making it harder for staff to find. Staff said the paperwork could reduce the time available to spend with people.
“Information was stored in multiple locations which made accessibility difficult.” from the report
Occasional medicine delays
needs fixingPeople were sometimes without prescribed medicines because of problems in the external supply system. Staff had taken steps to reduce delays and monitored people's health when they occurred.
“Despite these improvements, there remained some issues within the external system which meant that people were still, on occasion without their prescribed medicines.” from the report
- 01How will you make sure every person has a clearly recorded mental capacity assessment where needed?
- 02How are Deprivation of Liberty Safeguards conditions recorded, checked and followed in daily care?
- 03How often are prescribed medicines delayed, and what action is taken when a medicine has not arrived?
- 04How will staff find important care information quickly while the current record system is being reviewed?
- 05What evidence can you show that the improvements found in this inspection have been sustained since April 2021?
This was an unannounced focused inspection checking compliance with registration conditions and covering Safe, Effective and Well-led; ratings for the other key questions were carried over from the previous comprehensive inspection. This explanation was written from the published report of 22 May 2021 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.
What inspectors found, January 2021
The Martlets was rated Inadequate and placed in special measures after inspectors found unsafe care, weak leadership and repeated failures to improve.
This was an announced, focused inspection on 3 September 2020. Inspectors also reviewed records remotely, spoke with people, relatives and staff, observed care, and checked medicines, staffing, training and management systems.
They found serious risks in care and treatment. Medicines were missed, people were not always protected from malnutrition or dehydration, health changes were not always acted on, and falls were not always followed up safely. Staffing had improved in some ways, but staff were not always deployed to meet people's needs promptly.
Some staff were kind and caring, and infection control measures for COVID-19 were found to be safe. However, staff training, agency staff checks, records and management oversight were not reliable enough.
The overall rating fell from Requires Improvement to Inadequate. Safe and well-led were rated Inadequate, while effective was rated Requires Improvement. Caring and responsive were not assessed during this inspection, so their previous ratings carried over.
Kind staff
Inspectors saw staff being kind, caring and attentive. Some people and relatives said staff worked hard during the pandemic.
“We observed staff being kind, caring and attentive to people's needs.” from the report
Some staffing improvements
The home had introduced a tool to assess physical and health needs, and daytime staffing levels had increased since the previous inspection.
“Since the last inspection, staffing levels during the day had increased.” from the report
Medicines were missed
seriousSeveral people did not receive prescribed medicines because medicines were unavailable or staff made errors. In one case, missed heart medicines contributed to a potentially life-threatening situation.
“People had not always been provided with medicines prescribed to help manage their health conditions.” from the report
Nutrition and hydration risks
seriousPeople at risk of malnutrition or dehydration were not always supported according to their care needs. This included missed nutritional supplements, inadequate monitoring of weight and insufficient action when fluid intake was low.
“The provider had not ensured people were protected from the risk of malnutrition.” from the report
Staffing and training
seriousStaff were not always deployed to respond promptly, including when two staff were needed. Agency staff competence was not always checked, and some staff did not receive the planned supervision or training.
“Although improvements had been made, the provider had not ensured they had deployed enough staff to meet people's care and treatment needs.” from the report
Weak management oversight
seriousAudits and improvement plans identified some problems but did not set clear owners or deadlines, and repeated shortfalls remained. Frequent changes in managers also affected the home's ability to improve.
“The provider had not taken enough action to ensure this improved and had not complied with the Warning Notice.” from the report
- 01What checks now ensure every person's prescribed medicine is available and given on time, including when medicines are out of stock?
- 02How are weight loss, malnutrition, dehydration and nutritional supplements monitored, and who acts when records show a problem?
- 03How quickly are changes in health, falls and head injuries reported to healthcare professionals and followed up?
- 04How do you decide and monitor staffing for people's physical, social and emotional needs, including when two staff are required?
- 05What evidence can you show that improvement actions have clear deadlines, named responsibility and are being completed?
This was a focused inspection of Safe, Effective and Well-led, including infection control; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 15 January 2021 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of The Martlets
7 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- May 2021Requires improvementcurrent ratingup from InadequateSafe: GoodEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2021Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- October 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 17 December 2010.
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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