Marlfield Care Home With Nursing

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.

The service was in breach of legal regulation in relation to good governance.

This service scored 66 (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.

There was a positive safety culture. Relatives told us staff informed them of any concerns and safety incidents which involved their loved ones.

Staff spoken with understood and described the processes to enable them to identify and report safety incidents, which were then reviewed by senior management. In order to assess if any further actions were required for the person’s safety and well-being. They also reviewed incident data and identified if there were any emerging trends which required wider action for people's safety. Staff told us how a person had experienced increased falls recently, so their falls risk assessment was reviewed and checks completed to confirm their falls alert equipment was working. Staff confirmed they were provided with feedback about the outcomes from 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.

Relatives told us they felt overall people’s transition to the home was well managed. People were provided with key information about the service in an information sheet, to inform them and help them settle in.

Staff were provided with an overview of new people and their needs prior to the commencement of their care, via their pre-admission assessment. Staff also had access to up-to-date information about people and key information about them through the handover sheet.

People had emergency admission packs to ensure key information about them could be shared with other services if required, if they needed to be admitted to hospital. Staff were updated about any changes to people’s care at the staff shift handover.

The provider had not consistently kept people safe from harm but has been working with staff to make and embed the required improvements.

Several safeguarding incidents had been raised earlier this year and since closed. The registered manager and the management team immediately investigated and took actions in collaboration with partners, to keep people safe. Actions taken included, reviewing and strengthening practices within the home, such as how checks were recorded and monitored for people's safety, increased spot checks on staff’s practice and re-issuing the provider's safeguarding and whistleblowing guidance, to ensure all staff were aware of what, how and when to report concerns. The changes made will take further time to fully embed and evaluate.

However, people and relatives told us they felt safe and we saw people were relaxed in the company of staff. Staff had completed safeguarding training and those spoken with understood what abuse was, what they should report, to whom, when and how. The provider ensured learning from safeguarding’s was shared across their services through learning bulletins.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found applications had been submitted where required and senior staff were aware of recent legal updates in relation to DoLS.

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 used a range of tools to identify and assess potential risks to people and ensured where risks were identified, measures were in place to mitigate them. Staff understood how risks to people were to be managed and had received relevant training in relation to areas such as moving and handling, managing the risk of choking and behaviour support. People were provided with any equipment they required to manage risks to them, for example from falling or skin damage. People were seen to be supported by staff to mobilise safely. Where people had clinical risks related to stoma, catheter or wound care, appropriate care plans and risk assessments were in place.

Staff respected people’s wishes about their care and how they wanted risks to be managed. We saw some people had stairgates fitted to their bedroom doors which they told us prevented anyone from accidentally wandering into their room.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had processes to assess and mitigate the risks associated with Legionella, a bacterium that can cause Legionnaires’ disease, however, recently trace levels of Legionella had been found in cold water samples taken from 1 secure area of the home. The risk to people and staff had been assessed as low. The provider had processes in place to ensure regular water temperature testing took place as required.

The provider ensured risks related to fire, asbestos management, electrical and gas safety and equipment were assessed and any recommendations, such as in relation to fire safety had been completed. Staff had completed relevant fire training and drills.

The provider had refreshed the internal environment of the service, which included replacement flooring throughout the communal areas and corridors.

Whilst there were sufficient numbers of qualified, skilled and experienced staff. The provider did not always ensure evidence of all staff pre-employment checks had been obtained as required.

Some people and relatives said they felt at times more staff were needed and greater continuity of staffing. A person said, “Sometimes I wish there were more staff as I have to wait but usually its good” and another commented, “I would prefer to see more regular staff.” However, overall people were satisfied with both the staffing levels and staff’s skills. The registered manager monitored staffing levels. We saw there were enough staff deployed to support people safely.

There was a high use of agency staff, especially care staff, to ensure sufficient staff were deployed. The provider used staff from 2 agencies to provide continuity for people. However, a number of new staff had recently been recruited and were waiting to start their role, which will reduce reliance upon agency staff.

Not all aspects of staff pre-employment recruitment checks were fully robust. We identified gaps in the records for a permanent member of staff which had not been risk assessed. The registered manager acted immediately to address this. Staff profiles supplied by the 2 staffing agencies did not demonstrate all required pre-employment checks had been completed. The provider immediately liaised with both agencies to ensure they made the changes required.

All staff including agency staff had an induction to their role and ongoing training specific to their role. Staff completed learning disability and autism training which met national standards, or this was being arranged.

There was a lack of evidence to show regular staff supervisions had taken place. The registered manager was already aware of this and taking action. There was evidence care staff underwent observations of their practice. The provider had processes to manage poor staff performance or misconduct, and relevant actions had been taken where required.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and relatives told us the home was clean. The premises and equipment were overall seen to be clean and hygienic. Staff had completed relevant training and had access to the provider’s guidance. Staff were seen to use the personal protective equipment (PPE) provided. The home has a food hygiene inspection score of 5 which is very good. Processes were in place to audit the home’s infection control practices and showed an outbreak of infection during May 2026 had been well managed and contained.

However, we identified some areas of concern, for example, in the kitchen, where we saw some uncovered sandwiches and a dirty fan. In the kitchenettes which were located on both floors staff had not labelled all foods with the date of opening. The registered manager acted immediately to address these issues.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff involved people in medicines planning, including when changes happened. Staff stored medicines, including controlled drugs (CDs), and medical oxygen securely and maintained appropriate records for residents’ CDs. They recorded fridge and room temperatures, which ensured medicines remained within manufacturers’ recommended ranges. We identified concerns with the storage of a few controlled drugs, which staff were made aware of.

Staff recorded the application of creams used during personal care in their e-care records system. A member of care staff showed us where they stored these creams. The creams we inspected were labelled with opening dates. The staff member explained how and where they recorded cream applications and where they could find additional information about them.

Staff administered medical oxygen at the service. Administration records provided assurance that people were administered medical oxygen at the prescribed flow rate. Records to demonstrate that planned preventative maintenance of the oxygen concentrator had been undertaken were less clear. When we raised this with staff, they identified that latest template record sheet was not being used which was then implemented, resolving our concerns.

We reviewed a section of paper medicines administration records (MAR). The labelling and MARs of medicines for a few people lacked clarity, there was a lack of health and safety information about a medicine for staff. We also identified variation in the quality of medicines-related records within the care plans and "when required" (PRN) and variable dose medicines protocols. These records lacked sufficient personalised and individualised information to ensure different staff would consistently administer these variable dose and frequency medicines to meet people’s needs. We raised these concerns during the inspection and via verbal feedback at the end of the inspection. Following the inspection the registered manager provided their ongoing operational action improvement plan. This contained details of actions that had taken and they were now planning to undertake following the inspection.