Marlborough House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff understood what to report and how and followed the provider's incident reporting processes. Staff logged incidents, which were then reviewed by senior staff and any required actions were identified and remained open until they were completed. For example, if a person had a wound the incident remained open and was regularly updated until it healed. The person’s care plan was also updated with the incident reference number, which demonstrated the incident has been noted and any relevant action taken.

The registered manager analysed incidents monthly to identify trends and then shared any learning across the team, which staff confirmed. Professionals reported they were also informed of relevant safety incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff worked with other professionals to plan people's safe transition into and out of the service. The registered manager provided examples where either people’s admission or discharge had been delayed, as staff had assessed that to transfer the person as planned was unsafe, due to external factors. Staff ensured any moves for people only took place when it was safe to do so.

Staff told us they were updated at the staff shift handover about any new people admitted or changes to people’s care. On the day people were admitted, staff completed a pre-admission checklist, which ensured critical risk assessments for people's safety were completed promptly.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff completed relevant training in relation areas such as moving and handling, the use of bed rails, falls awareness, pressure ulcer prevention and positive behaviour support. People told us they felt safe and said staff checked upon them regularly.

People’s care plans and risk assessments identified and mitigated a range of risks to them. Associated either with their medical condition, such as diabetes or epilepsy, or safety, such as falls and skin viability. People were consulted about how they wanted identified risks to be managed. For example, a person did not wish to be re-positioned to manage their risk of skin breakdown. Staff had discussed the risks of not doing so with them and gained their agreement to be re-positioned at certain times. People’s records demonstrated that with their consent they were regularly re-positioned.

People had any equipment they needed. People were all assessed for the type of mattress they required for their clinical needs. People’s daily records showed they were transferred, using the correct equipment and number of staff required, in accordance with their care plan guidance.

People did not have their liberty restricted unnecessarily. For example, if people required bed rails to keep them safe, their use was risk assessed and people were consulted about their use.

The provider did not always detect all potential risks in the care environment.

We observed 1 fire door was not closing fully which was a risk in case of fire. There were trailing wires on the floor in 4 bedrooms and the garden gate was shut but not locked on the morning of the first site visit. The provider’s fire drill record also needed to provide a greater level of detail. The registered manager took immediate action to address these issues as soon as we brought them to their attention.

However, overall, the environment was seen to be safe. The provider had processes to ensure required safety checks were completed in relation to electrical, gas, fire, water and equipment safety. A person confirmed, “We have regular fire drills.” Staff ensured people’s air mattresses were set correctly for their weight and daily checks were completed on their functioning. Staff completed health and safety training.

The provider had made improvements to staff recruitment checks; but one aspect was not fully robust. There were sufficient qualified, skilled and experienced staff who were well supported in their role.

Staff files evidenced the pre-employment checks completed. Staff were required to provide a full employment history including the reasons for any gaps and checks had been made with the Disclosure and Barring Service (DBS). We saw checks had not always been made in relation to all previous health and social care roles staff had held. We spoke with the provider who immediately amended their policy and procedures. It will take further time for them to be able to demonstrate these changes have been embedded.

People told us they felt care staff were very busy. Feedback included, “They do need more [staff] I think because they always seem to be very busy.”

However, staff said they felt able to meet people’s needs. The registered manager used a dependency tool to determine and monitor staffing requirements. The home was fully staffed apart from 1 vacancy for ancillary staff and regular agency staff covered any gaps due to holidays and leave. We observed there were sufficient staff deployed to meet people's needs and to have oversight of people's safety when they were in the communal areas of the home.

The provider had a workforce coordinator who facilitated and ‘buddied’ new staff throughout their induction period, training and competencies, including completion of the Care Certificate. This enabled new staff to receive dedicated and consistent support. Staff also completed a range of online and face to face training, including the provider's mandatory training and role specific training. Staff said they received regular supervision.

The provider assessed and managed the risk of infection; some aspects of cleaning required improvement.

We observed that although cleaning took place throughout the 2 site visits, some aspects required improvement. For example, although bedroom cleaning charts were marked as complete. We found 1 person’s bedroom had several dusty surfaces and there was still debris on the floor. Due to the heat, a number of fans were in use, and we saw 4 required cleaning. We also found 2 freezers needed defrosting. The sluice door was open on the first day. This was fed back to the registered manager who took the required action to address this for people.

However, overall, the home was clean, and we did not note any malodours. People and relatives did not have any concerns about the cleanliness of the service. There were handwashing facilities throughout the home. Staff were seen to wear the personal protective equipment provided. Staff had completed relevant training. The kitchen had a food hygiene rating of 5 which was very good. The provider’s annual infection control statement confirmed there had not been any significant events. People were seen to be clean and well groomed.

The provider had made improvements to ensure safe medicines management: but one aspect was not fully robust.

People had protocols in place for medicines people used ‘as required’ but 2 people’s protocols for paracetamol lacked clear directions regards whether to administer 1 or 2 tablets. A person’s laxative protocol also lacked clear directions regards whether to administer 1 or 2 sachets, or when to seek medical intervention. We discussed this with the clinical lead who took immediate action to address this. It will take further time for them to be able to demonstrate these changes have been embedded.

However, processes were in place to list people’s medicines when they entered the home and to store and dispose of them safely. People had body maps to guide staff about the application of their topical creams, which if flammable, had risk assessments in place. Staff all completed competency assessments to ensure they understood how to prepare and administer thickened fluids for people safely. People did not have any concerns about how their medicines were managed. The provider had processes in place to report and investigate medicines errors.