We carried out a review of the data available to us about Marlborough House on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Marlborough House, you can give feedback on this service.
We found the following examples of good practice.
The provider had ensured people could have visitors safely in accordance with national policy. People had visitor care plans to ensure their social contact needs were met and relatives pre-booked their appointment.
All visitors, including relatives, contractors and professionals were required to complete a lateral flow test prior to entry, to prevent the spread of infection and to follow the provider’s infection control guidance. The provider had fitted a thermal scan camera in reception, to identify if anyone entering the service had an elevated temperature. Staff also took visitors’ temperatures and recorded their details for the purposes of the track and trace scheme.
People’s nominated, named visitor could visit them within the service. They were required to follow the provider’s guidance, and to wear personal protective equipment (PPE). People also had visits with their other visitors outside in the garden, using the provider’s visiting pod. People had regular contact with their families outside of visits, using their phones and iPads.
People were required to undertake a COVID-19 test prior to admission. They then self-isolated in their bedroom and their temperature and wellbeing were monitored. People and staff all participated in the national whole home testing programme.
Staff including agency staff, only worked at the service. Staff had undertaken relevant infection control training and wore the PPE provided appropriately. Staff were allocated to work on one floor only. The provider had converted an upstairs bedroom into a staff room, to ensure staff could stagger their breaks and remain on the same floor.
The service was clean and hygienic. Staff ensured high contact areas were cleaned frequently. Windows were open for ventilation. Staff laid up separate dining tables for people, to enable social distancing. There was clear separation of clean and dirty laundry. The provider had ensured the seating provided for the visiting pod was both comfortable and easy to clean between visitors.
The registered manager had accessed the support provided by the local specialist matron for care homes and the Clinical Commissioning Group (CCG). They attended the CCG's fortnightly care homes COVID-19 meeting, to keep themselves updated regards best practice both nationally and locally. The meeting also provided them with an opportunity to ask questions and seek any guidance or support required.
The registered manager and the provider regularly assessed the robustness of the home’s infection control policies and processes, through a range of audits and staff supervisions. The registered manager ensured the service was well stocked with PPE.
Marlborough House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Marlborough House is registered to provide personal care and accommodation to up to 40 people who are frail or living with dementia. Accommodation is provided in a converted residential dwelling over two floors. At the time of our inspection 35 people were using the service.
Following the last inspection in June 2016 we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; Safe and Well led, to at least good.
At the last inspection we found that improvements were needed in obtaining a full employment history for new staff before they were employed At this inspection we found that improvements had been made in this area and a full history was available for all new and existing staff. We also found that action had not been taken when the systems in place had identified shortfalls. At this inspection we found action had been taken and improvements made.
People told us they felt safe living in the home. One person said, “I am happy living here and I feel very safe.”
There were systems and processes in place to minimise risks to people. These included a robust recruitment process and making sure staff knew how to recognise and report abuse. There were sufficient staff to safely meet the needs of people living in the home. People told us they thought there were plenty of staff and they did not have to wait long for their call bells to be responded to. Records showed that there were adequate numbers of staff available to meet the assessed needs of people in a timely manner.
Medicines were managed safely, securely stored, correctly recorded and only administered by on duty nurses and team leaders that were trained and assessed as competent to give medicines.
People received effective care from staff who understood their needs. Staff were able to tell us about people’s specific likes and dislikes. People told us they thought staff were well trained and understood them well. The registered manager and staff were very pro-active in arranging for people to see health care professionals according to their individual needs.
People and relatives told us that the food was good. We reviewed the menu which showed that people were offered a variety of healthy meals. We saw that food was regularly discussed and recorded at resident meetings.
All staff attended induction training before they started to work in the home. All staff said they had plenty of opportunities for training and the organisation also promoted dementia awareness training for all their staff.
People could enjoy a full programme of activities and staff had built up links with the local community to ensure people could stay in touch with organisations such as their place of worship and the local school.
People said they received care and support from caring and kind staff. Comments included, “The staff are all very caring, They listen to you and make you feel important.” And “They are all very nice very caring and very respectful.”
People received care that was responsive to their needs and personalised to their wishes and preferences. People were able to make choices about all aspects of their day to day lives.
People told us they could talk with staff and the registered manager if they wished to raise a concern. One person said, “I know who to talk to if I have a complaint but it has never come to that.”
People were supported at the end of their life to have a comfortable pain free death. Care plans showed people’s advance decisions were taken into consideration and acted upon.
There were formal and informal quality assurance systems in place to monitor care and plan on-going improvements. There were audits and checks in place to monitor safety and quality of care.
The service was well run by a registered manager who had the skills and experience to run the home so people received high quality person-centred care. The registered manager led a team of staff who shared their commitment to high standards of care and clear vision of the type of home they hoped to create for people.
When we last inspected the service on 6, 10 and 19 March 2015 we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponded to regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found all pre-employment checks had not been completed prior to staff being offered employment. The provider had effectively identified shortfalls in the service but had not always taken action to make the required improvements. People’s care records required improvement.
After the inspection the provider sent us an action plan and told us they would make the required improvements to meet the regulations by December 2015. At this inspection we found the provider had made some improvements to address the concerns we found at our previous inspection. However, we found one continuing breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to the governance of the service at this inspection. You can see what action we told the provider to take at the back of the full version of this report.
A range of audits and self-assessments were routinely undertaken across the service. We found these assessments and audits to be comprehensive and had assisted the provider to identify shortfalls so that action could be taken to improve the service. However, we found insufficient action had been taken to address these concerns and the provider had not monitored the implementation of their inspection action plan through to completion. We saw some action had been taken and some improvements had been made in relation to pre-employment checks, care records and best interest decision making, However, more time was required to ensure these improvements were fully completed and had become sustained in the service. Whilst work had taken place it had not resulted in the required improvements the provider told us they would make in their action plan to meet the regulations.
The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service is required by a condition of its registration to have a registered manager. The registered manager had become registered with CQC in December 2015.
Staff were able to demonstrate their understanding of the risks to people's health and welfare and people told us they received care that met their needs. Risks associated with people's care and support needs had been identified and guidance provided to help staff protect them from harm. People's care plans provided staff with the information they needed to know how to keep people safe and meet their needs, wishes and preferences.
Staff had received training to support them to effectively meet the individual needs of people. Staff had a good knowledge of their responsibilities to keep people safe from abuse. Staff sought people's consent before they provided their care and support.
There were enough staff to meet the needs of the people that lived at the home. People were positive about the staffing levels and said they received support quickly when they needed it.
People received their medicines as prescribed and had access to healthcare services when they needed them. People liked the food and told us their preferences were catered for. People received the support they needed to eat and drink enough to support their nutritional and hydration needs.
People were treated with kindness, compassion and respect. Staff promoted people's independence and right to privacy. The staff were committed to enhancing people's lives and provided people with positive care experiences.
People knew how to make a complaint. People told us the registered manager and staff would do their best to put things right if they ever needed to complain.
People and staff's views about the management of the service were positive. The registered manager had promoted a culture that put people at the centre of the work they did. Staff felt she was approachable, listened to them, asked for their views to improve the quality of the service provided. People felt involved in their care. People were supported with activities, and enjoyed time spent with staff.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.
Marlborough House provides nursing care for up to 40 older people who are frail or living with dementia. Accommodation is provided over two floors. At the time of our inspection 24 people were using the service, two of which were living with dementia.
In September 2014 we undertook an inspection and found there were six breaches of the regulations. We took enforcement action for three of these breaches in relation to people’s care and welfare, nutrition and the provider’s monitoring of the service. We told the provider they needed to comply with these three regulations by 31 October 2014. We inspected the service again in November 2014 and found the provider had made the improvements to meet the requirements of these three regulations. In September 2014 we also took compliance actions for the other three breaches relating to safe management of medicine, staff support and people’s records. The provider sent us an action plan telling us they would make these improvements by end of February 2015. During this inspection we checked whether the provider had taken action to address these three regulatory breaches.
During this inspection we found the provider had taken action to address some of the regulatory breaches and concerns raised. There had been a delay in getting the improvement work started due to management changes. We found the provider had addressed this concern by making additional staff and management resources available to support the improvements identified. A new manager had been appointed and it was evident that increased action had been taken following the appointment of the new manager.
A range of audits and self-assessments were routinely undertaken by several senior managers across the organisation. We found these assessments and audits to be comprehensive and had supported the provider to identify similar concerns to those we found during this inspection. However, we found insufficient action had been taken to address these concerns. In the absence of a robust overarching risk based improvement plan the provider’s improvement efforts had become fragmented. Individual action plans had not being completed and monitored for their effectiveness. The work that evidently had been taking place had not resulted in the required improvements.
People were supported by nursing staff to take their medicines. However, medicine administration records continued not to be completed consistently to ensure accurate information was available so staff would know that people had taken their medicines as prescribed.
People, relatives and staff acknowledged progress made to establish a stable management team in the home and spoke positively about the new manager in post at the time of our inspection. Though staff had started to receive supervision improvements were still needed to ensure the supervision and appraisal system was implemented routinely to create development plans for staff.
Recruitment practices were not sufficiently robust to protect people as far as possible from individuals who were unsuitable to deliver care to people.
People were increasingly encouraged to be involved in the planning of their care. Where people lacked the capacity to agree to the restrictions the provider placed on them to keep them safe, the provider made sure people had the protection of a legal authorisation instructing them to do so. We recommended the provider seeks guidance on how to record the best interest decisions that lead to Deprivation of Liberty Safeguards (DoLS) applications being made for people.
Staff told us the quality of care plans had improved and gave them the information they needed to know how to care for people to meet their needs and preferences.
People were cared for by staff who were kind and respectful of their needs and wishes. Their dignity was promoted through thoughtful consideration. The provider’s complaints process ensured people’s concerns were addressed appropriately.
People and their relatives were complimentary about the quality of care provided. They appreciated the friendliness of staff and the homely atmosphere. People were encouraged by staff to treat Marlborough House as their home. People and their relatives were increasingly encouraged to give their views about the home and their feedback was used to make improvements. The provider was preparing to send out their first quality survey to people and their relatives.
A registered manager was not in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered person’. Registered persons have legal responsibility for meeting the requirements in the health and Social Care Act 2008 and associated regulations about how the service is run. The provider had appointed a new manager in January 2015 and they were completing the assessment process for becoming a registered manager with CQC.
We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These correspond with the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.
In this report the name of a registered manager appears who was not in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.
We carried out this inspection to ensure the provider had taken action in relation to the enforcement action we took following our inspection of 15 September 2014. The provider was non-compliant with three further regulations but these will be checked upon at a later date when the provider has confirmed they have completed their action plan in relation to these regulations.
The provider had decided to no longer provide respite care which had removed the risks to people who had been receiving this service.
People had a range of care plans in place to meet their identified needs. Where risks to people's health or well-being had been identified there were plans in place to address them. Monthly checks had taken place to monitor people's health. Systems were being introduced to ensure staff had responsibility for ensuring people's care plans were updated. An improved handover sheet had been introduced to ensure staff were aware of people's needs and potential risks to them, although the provider needed to make sure the information on this was always updated. People felt the social care needs provision through the activities programme needed to be reviewed.
People had nutritional care plans in place and risks to them had been identified and communicated to the chef. People had food and fluid charts in place where required but staff needed to ensure these were totalled up each day to enable them to monitor people's fluid intake. People's weight was monitored and the risks of malnutrition monitored. Staff had received relevant training to support them. We observed people's experience of the lunchtime service could be improved.
The provider had taken action in relation to previous report recommendations from their external consultant. There had been improvements in relation to the monitoring and analysis of falls. Systems to enable people to provide feedback had been improved but the provider needed to consider how they could monitor the call bell system. There had been changes in the management structure and systems that were being embedded.
There were 35 people using the service on the day of the inspection. As part of this inspection we spoke with five people who use the service, the registered manager, the registered provider, six staff and the operations manager. We also reviewed records relating to the management of the home which included, ten care plans, daily care records, staff records and reports.
Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.
Is the service safe?
The service was not safe although people we spoke with told us that they felt safe. One person commented 'Yes, I mostly feel safe. They respond quickly to the call bell.'
People's medicines were not always handled safely and records of medicine administration were not always completed. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to medicines.
Where people had repositioning charts in place to manage the risk of them developing pressure sores. These had not always been fully completed to demonstrate that people's care had been provided. People's records were not always kept securely. We found personal records and staff records in communal areas. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to records.
CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.
Is the service effective?
The service was not effective. People who received respite care did not have nutritional care plans in place to meet their identified needs. There were not sufficiently robust arrangements to manage identified nutritional risks to all people. When asked about the sharing of information about people, one person told us 'It's not always shared effectively.'
People had not always received support to eat in accordance with what was documented in their nutritional care plan. One person told us 'I have to ask to have my food chopped. Most staff don't ask if I want my food chopped.' The risks to people of malnutrition had not always been effectively monitored. We have taken action to ensure that the provider becomes compliant in relation to people's nutritional needs.
People told us 'Staff seem trained.' However we found that not all staff had completed refresher training as required by the provider's guidance. Staff had not received supervision as frequently as documented in the provider's supervision policy. The provider had not ensured that staff had received an annual appraisal of their work. This meant that not all staff had received the opportunity to update their training, receive supervisory support or to review their progress. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting workers.
Is the service caring?
The service was caring. People told us 'Yes staff treat me with dignity and respect and 'On the whole they are very good. I have no complaints about any of them.' People were satisfied with their care. They told us that staff promoted their independence. Staff were observed to be caring and kindly towards people. Choices were provided to people about their care for example with regards to where they wanted to eat.
Is the service responsive?
The service was not responsive. People who received respite care did not have care plans in place to meet their identified care needs. When people had returned to the service for further periods of respite care there was a lack of evidence to demonstrate that their needs had been re-assessed. People who were permanently accommodated did not always have all of the care plans they needed in place in a timely manner. There was a lack of ownership with regards to whose responsibility it was to write people's care plans. As a result the operations manager told us 'Care plans aren't as responsive as they should be.' We have taken action to ensure that the provider becomes compliant in relation to people's care and welfare.
Is the service well-led?
The service was not well led. Staff and people were generally satisfied with the leadership of the service. However, the leadership was reactive rather than proactive. Some learning had taken place following incidents. The measures which had been taken were insufficiently robust to ensure risks to people especially those receiving respite care had been effectively identified and managed. The provider's operations manager told us that the service was 'Short on systems at the moment', and that the service 'Falls down at the management tier.'
There had been insufficient analysis of accidents and incidents by the registered manager to identify possible trends so that action could be taken to prevent incidents from reoccurring. We have taken action to ensure that the provider becomes compliant in relation to assessing and monitoring the quality of the service.
Relatives told us they considered the staff provided excellent care. People we spoke with said they were happy with the care and support they received.
We observed staff providing care and support and found that they were respectful and did not rush people. However we observed that some care provided did not protect the dignity and privacy of people.
People's records were reviewed on a regular basis but at the time of our visit the provider did not have a system to monitor, assess and learn from incidents and accidents and as a result the provider was unable to continually assess the quality of care at Marlborough House.
The inspection team was led by a Care Quality Commission (CQC) inspector joined by a practicing professional and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of service.
Some people were unable to tell us about their experiences due to their medical conditions. To help us to understand the experiences of people, we used a Short Observational Framework Inspection tool (SOFI), which is a specific way of observing care to help us understand the experience of people who could not talk to us.
People who lived at Marlborough House told us that they were happy living at the home. One person told us 'I am well cared for'. Another person said 'there are lovely staff who look after me'.
When asked, people who lived at the home told us they were provided with choices at meal times. We observed members of staff were sensitive to how people demonstrated their choices and decisions. This meant people had their choices understood and respected.
They told us the food was good and they looked forward to meal times.
Relatives told us that the home was lovely, the staff were good, and that issues were dealt with promptly. They told us that they believed their relatives were safe living at Marlborough House.