Marlfield Care Home With Nursing

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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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

This service scored 68 (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 continues to work on developing a shared vision, strategy and culture for the service.

The provider and the registered manager were fully aware there have been recent issues within the culture of the service, which negatively impacted some people’s care. They have been and continue to work with the staff team to develop a shared vision and culture for the service.

This has involved engaging staff in discussions about the provider’s values, which include integrity and respect, professionalism, making a difference, continuous improvement and working as 1 organisation, whilst also identifying with staff what the service should offer to people. Staff have been involved in developing the home's mission statement, which also focuses on working as a united team to achieve, ‘the best possible outcomes’ for people. Agency staff have been included in the changes and have an induction to ensure they understand the behaviours and values required of them.

The registered manager had made changes to systems, processes and monitoring to ensure all staff fully understood and were supported to fulfil their duties and responsibilities. The changes made will take further time to fully embed and to evidence staff on all shifts are working together as a team, at the required standard.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There had been significant changes within the management team over the last 12 months, with changes both within the clinical and deputy roles. The new team have been supported by the provider through these changes and with making the required changes to the culture of the service and processes. This has been achieved through regular visits and support from the service manager, the provider’s clinical lead, a management day and participation in the provider's management workshops and meetings.

The registered manager understood their legal responsibilities and the risks and challenges facing the service. Staff, people and relatives said they felt able to speak with members of the management team about any issues as needed.

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

Staff spoken with were familiar with the provider’s whistleblowing policy and had access to the ‘How to whistleblow guide’. Staff said they felt able to challenge practices and to raise issues with management as required. A staff member said, “We have the open door policy and can speak to the manager, employee assistance programme, managers here are brilliant.” The deputy manager told us they started work early, which gave night staff the opportunity to speak with them if required.

The registered manager and provider had investigated concerns effectively; lessons had been learnt and actions taken for people’s safety as required.

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 provider had a range of polices and processes in place which set out their commitment to promoting an equal and inclusive workplace. The diversity of the workforce was recognised with the provision of a multi-cultural faith room for staff's use. There had been cultural celebration days, which provided opportunities for staff to share aspects of their heritage through food, entertainment, and social activities.

The registered manager was committed to ensuring a workplace where all employees were treated with dignity, fairness, and respect. Staff confirmed they felt their contribution was recognised and they were well treated.

The provider did not always have good governance processes. Some aspects of the governance processes and some aspects of record keeping were not fully effective and robust.

Medicines, MCA 2005 and staff file audits were completed but had not identified the issues we found, therefore there was the potential people could be harmed. As these issues were not identified through the provider’s existing monitoring processes.

People's daily notes did not always demonstrate they were repositioned as often as required within their care plan. Although records showed staff moved people regularly to provide other aspects of their care and there was no evidence to indicate they were at increased risk of developing pressure ulcers. Staff's record keeping needed to be more consistent. The registered manager and the provider have been responsive and acted in relation to the issues identified.

However, staff audited and monitored a range of aspects of the service to identify areas for improvement. The service manager told us the management team completed a monthly in-depth review of various aspects of people’s care and needs, including incidents, behaviours, dependency levels and oral care. This has enabled them to review people’s care data holistically and to cross-reference findings from different audits and measures, which has made the process more effective. There was a service improvement plan which provided an overview of all actions staff were either working upon or had completed to drive improvements.

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 made referrals for people as required to a range of professionals and agencies, to ensure any identified needs were assessed and met. A professional confirmed staff worked very effectively with them and utilised any advice or guidance provided to both develop their knowledge and skills and to improve people’s experience.

The home had local connections and support. This had benefited people as a donation had been used to make improvements to the courtyard for people. Staff and people were involved in fund raising activities for the amenities fund, which provided entertainment and social activities for people.

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.

People and staff were encouraged to speak up with their ideas which they felt were listened to.

Processes were in place to ensure when things went wrong, management encouraged reflection and learning to reduce the likelihood of repetition. Learning identified both through internal and national safety incidents was shared across the providers homes through bulletins, clinical meetings and clinical governance processes.