Marham House Care Home

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. This is the first assessment for this newly registered service. This key question has been rated requires improvement and we found a breach of regulation 12, safe care and treatment. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 53 (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 did not always have a proactive and positive learning culture. Potential concerns about safety were not always identified and therefore investigated fully with actions taken.

The provider had processes for staff to report incidents, near misses, and safety events and there were processes in place to share learning across the provider's services. However, evidence of learning from incidents did not consistently result in improved practice.

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Some people and their relatives felt able to raise concerns and these would be acted upon, however, others did not feel able to raise their concerns about the service. One person’s relative said,” Communication, other than invoicing, seems almost non-existent.” Another relative told us, “They are incredibly slow to take action to solve problems or issues raised.”

The provider did not consistently work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Whilst systems were in place to support people on admission with risk assessments undertaken to ensure people were safe. Care records required improvement to ensure they were up to date and accurately reflected people’s needs. The management team were reviewing everybody’s care plans and risk assessments to ensure accurate up to date care information was in place to guide staff.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us Marham House was a safe place to live. One relative told us “[Family member] loves the home and feels safe, well cared for and relaxed there its a big relief to her after she struggled in her own home for some time.

We observed people appeared relaxed in the company of staff and they were familiar with the covering manager and comfortable in their presence.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service was aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s records were not always consistent, accurate or up to date in order to ensure appropriate measures were in place to reduce the risk of poor nutrition, weight loss and skin pressure damage. For example, one person who had lost 6kg of weight in the last 11 months had only begun to have their weight monitored weekly since the start of January 2025.

A staff member told us another person, due to the risk of pressure ulcers, had to be repositioned every 2 hours, however, this information was not recorded anywhere in the care plan for staff to be aware of and follow this guidance. We checked the repositioned records and found gaps of significantly more than 2 hours. This placed the person at risk of developed pressure ulcers.

From our observations of care practice, we saw that records completed by staff were not always accurate and reflective of the care delivered. For example, one person’s care records had been completed by a staff member to reflect they had eaten their cooked breakfast when in fact, the food had been left in front of the person, untouched, for over 3 and ½ hours and no support or encouraged offered to eat it.

We found a cleaning cupboard left unlocked containing several items including dishwasher tablets and liquid cleaners. We asked staff to lock this cupboard. This could have caused harm should a person living with dementia have inadvertently ingested them.

The provider was receptive and responsive to our findings and took immediate action to address the concerns identified.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Essential safety checks had not been consistently carried out since a previously employed maintenance member of staff who had left in October 2024. This meant the routine testing of fire safety systems and carbon monoxide alarms had not been carried out as intended. This meant there was a risk safety system would not work as intended because any faults would not have been picked up. The provider took immediate steps to address this shortfall.

We also received a lot of feedback from people and their relatives about improvements needed to the external grounds. One relative said, “The part of the home that is neglected is the gardens. The raised beds need refilling with soil so they can be planted properly, they are full of weeds. This was promised for this year but has not happened.” Another relative commented, “Work on the back garden needs attention and investment.” The provider told us they were investing in the grounds and had plans to make the required improvements.

The internal environment people lived in was aesthetically pleasing and people had access to pleasant, well maintained indoor spaces. One person’s relative told us, “It is a high-quality environment, always very clean, nicely furnished, feels like a home not an institution. Lots of different rooms and areas for [people] to spend time in which I think makes life there more interesting, (with quiet spaces as well as more sociable ones) and as above plenty of activities going on.”

At this inspection, we received mixed feedback from people around staffing levels. Some people told us the staffing levels were not always adequate to meet their needs in a timely manner, however, others provided more positive feedback. Some relatives told us there were periods of the day when staffing levels were not entirely sufficient. One relative said, “Most of the time it seems that there are enough staff. However, during staff break times there often doesn’t seem to be anyone around as those remaining have so much to do.” And another relative commented, “At times, staffing levels appear to be a little low for the number of residents in situ, particularly at weekends. If a carer is asked to attend to a resident’s specific urgent need the staff are generally receptive, but sometimes if they are juggling other duties the response time can be a bit longer than ideal.”

Our observations were that there were sufficient numbers of staff but the deployment of staff needed improvement, particularly on the top floor where staff were busy and at times task focussed. A lack of experienced leadership resulted in a lack of co-ordination of staff, and we saw several times during our visit where some people were left for periods of time with little or no interaction. We fed this back to the provider so they could monitor this and provide direction and training where needed.

There were also people and their relatives that spoke highly of the staffing and many and told us that the permanent staff were kind and attentive. One relative told us, “There always seems to be a good number of staff whenever I visit and I believe this is the same in the night and early morning, as they are able to accommodate [family member’s] needs 24 hours a day.” Another relative said, “[Family member] is pleased with the level of staffing. The home has done very well to maintain the levels of staffing despite the national shortage.”

The provider did not fully assess or manage the risk of infection as some staff wore artificial nails during care delivery. The NHS in England advises that artificial nails have been linked to poor hand washing practices and more tears in gloves. These factors lead to an increased risk of transmitting bacteria to people. This had not been identified as a risk to people in any management audits.

We found the service was clean, tidy and free from odours. Ancillary staff were available to support cleaning and laundry within the service and we received multiple complements from people and relatives about the laundry service.

The provider did not always make sure that medicines were stored securely, administration was not always recorded sufficiently. We reviewed medicine administration and associated records for 12 people, observed staff giving people their medicines and we spoke with 3 members of staff about medicines.

Records we checked showed that overall people were having their regular medicines administered safely by staff who had recently had their competence checked. However, there were gaps in some records. Guidance information available to staff for the management of people’s medicines needed improvements such as for the safe application of medicated skin patches. Oral medicines were being stored safely; however, topical medicines were not being secured across the service.