Archived: Marland Court

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.The service was in breach of legal regulation in relation to good governance. The registered provider failed to implement robust systems and processes to demonstrate good oversight of the service; incidents were not appropriately acted upon to ensure people remained safe.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with openness and honesty.

Prior to this assessment we received multiple concerns from whistleblowers. They did not regard managers to be capable and compassionate and had not felt valued or listened to when raising concerns about the service.The service lacked strong leadership, and the management arrangements in place did not ensure the manager had sufficient support and guidance to maintain appropriate oversight of the day to day running of the service.

Where people displayed complex behaviours, managers did not explore strategies to better support them and to help reduce the risks. Staff were not protected or provided with the relevant skills and training; therefore, people were asked to leave their home and find alternative accommodation. Two people had been served with notice at the time of this assessment as the service could not meet their needs. This did not represent compassionate care and was stressful for people and their families.

From speaking to staff, reviewing accident and incident records and intelligence received into CQC we identified a number of incidents which had happened at the service, resulting in either staff being injured or staff leaving the service.

We were not assured that where staff chose to speak up, their views and anonymity were treated with the required levels of respect. Factors impacting on staff feeling safe and comfortable to speak up without fear of reprisals had not been considered by the provider. The culture overseen by the provider and management team within the service and wider organisation did not support staff to speak up internally or externally; staff did not feel able to comfortably raise concerns. A number of staff had recently left the service, some as a result of this, and had raised concerns with CQC. One member of staff we spoke with employed at the time of this assessment told us they felt intimidated by management and said, “I won’t be going back because of this and all the other issues. I have been apprehensive about raising any problems.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on information about risk, performance and outcomes, or share this securely with others when appropriate. There was no registered manager at the service. The last registered manager in post deregistered on 15 November 2023. Whilst managers had been in post, they had not made applications to register with the Care Quality Commission; the home had lacked the necessary oversight required in order to achieve compliance with regulations.

There was support for the manager from a Regional Manager. Our records show they remained the registered person for a sister home, were the Nominated Individual for the provider and we were told they also delivered aspects of face-to-face training for new employees. They did not have the time required to fully support the new manager in the role, especially given all the failings we identified at this assessment.

Risk assessments specific to people’s needs had not been addressed. The failure to identify such concerns prior to this assessment placed people at risk of harm from the poor assessment and management of risk.

Staff attended face to face training for moving and handling, delivered by the Regional Manager. We did not see any evidence the Regional Manager had completed a formal ‘Train the Trainers’ programme with certification. We were not assured the arrangements for the training and development of staff were effective; staff were not provided with all the required knowledge and skills needed to safely deliver the care and support people living at Marland Court required.

Electronic rotas were in place showing staff on duty, but changes made to staffing arrangements for Thursday 30 January were not reflected on the electronic rota, and a rota for week commencing 03 February 2025 was not yet in place. Rotas were not completed in a timely manner, which was not effective for people using the service or staff.

The registered provider failed to implement robust systems and processes to demonstrate good oversight of the service; incidents were not appropriately acted upon to ensure people remained safe. It is essential to have robust governance systems in place to identify concerns and improve quality and safety.

At the time of this assessment the provider was working with the local authority to improve the service. Concerns had been raised regarding the quality of the care and management of the service, and the provider was attending meetings with commissioners; health and social care professionals were also present. We received little feedback from external professionals and stakeholders in relation to the attitude and approach of the provider, staff and leaders in relation to collaborative working.

People were supported to maintain contact with their relatives, friends and people of importance to them. However, care records did not consistently reflect relative’s involvement in their development. Our findings were confirmed from feedback we received from people’s relatives.

People’s care records did not consistently reflect outcomes of joint working with health and social care professionals; however, staff and leaders gave positive feedback about partnership and collaborative working with health and social care professionals.We identified opportunities for further development in relation to partnership working with all stakeholders involved in the home.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

The service was failing in 3 areas as identified in our previous inspection, published on 20 October 2022. We identified repeat breaches in safe care and treatment, person centred care and good governance, and an additional breach in consent. The local authority had expressed similar concerns around poor management and the quality of care in January 2024 and again in November 2024, but at the time of this assessment the provider had failed to make the necessary changes to achieve compliance with regulations.

More robust audit processes to assess, monitor and improve the quality and safety of the service were needed in areas such as risk management, care records, incidents and staff training to help identify, learn and drive the improvements required.