Marlborough House

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 assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager ensured there was an open and positive culture within the service. Staff learnt about the provider’s philosophy and principles of care during their induction to their role.

There were systems and processes to enable the registered manager to have oversight of the quality of people’s care, to identify concerns and ensure any actions required were completed. These included the senior staff’s daily huddle which was used to identify and act upon any emerging issues and to reflect upon staff’s practice within the previous 24 hours, in relation to areas such as moving and handling, meal consistencies for people and consent. Management also completed a daily walk around which included seeking feedback and observations of staff’s interactions with people.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they were able to speak out and any concerns they raised were listened to. The provider had processes in place to enable staff to speak out. These included policies and procedures and speak up information, which provided staff with direct access to escalate concerns outside of the home's management, if required. Staff also had the opportunity to speak with management during supervisions, the daily huddle, staff meetings or the daily walk around.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The staff team was diverse. The provider had a range of polices to ensure all staff were included and treated respectfully, equitably and fairly. Staff confirmed they were treated fairly. The diversity of staff’s cultures were valued and celebrated. Staff were supported with childcare and religious observances.

Staff from all backgrounds were encouraged to take up opportunities for professional development. Staff had completed professional qualifications and then either taken up new roles within the home or moved onto roles within the providers other homes.

The provider had clear responsibilities, roles, systems of accountability and good governance overall but some aspects required strengthening. They used these to manage and deliver good quality, sustainable care, treatment and support.

The registered manager had a range of systems and processes in place to have oversight of the quality and safety of care provided, and to identify and address any concerns. Overall, these were effective at identifying issues and ensured required actions were allocated and tracked until signed off. The provider also completed a range of audits and regular quality monitoring visits. These processes ensured there was external oversight of the quality of the service.

CQC had been informed of notifiable events at the service.

However, aspects of some governance processes in relation to staff files, ‘as required’ medicines protocols, the environmental safety and cleaning required further review to ensure they were fully robust. The registered manager has already advised of the actions taken to address the issues found and has strengthened oversight. For example, additional weekly checks have been introduced on medicines people take ‘as needed’.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff worked in close partnership with a range of professionals from key organisations who provided positive feedback on their working relationships with staff at the home.

Staff took up training opportunities offered by external professionals and identified and sought training from specialists. For example, nurses had attended covert medicines training and a local hospice in response to staffs’ feedback, had provided them with training on priorities and planning, and advance care planning at the end of life for people.

The registered manager welcomed quality visits by external organisations from health and social care which enabled evaluation of different aspects of the care they provided.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were encouraged to identify their own learning needs and contribute to the development of the training programme for the home. Personal development courses have been introduced for nurses, team leaders and care staff. Staff have since requested and been provided with training courses in phlebotomy, catheterisation, suction and oxygen management. Staff then completed reflection and course reviews which demonstrated the impact of training upon them and their practice.

A tissue viability audit had been completed earlier in the year which identified issues in relation to consistency of nurses wound care records. The deputy manager has since produced a wound care guide for nurses to promote consistency across the team. Staff told us how useful they found the guide which was to be rolled out to the providers other services.