Marham House Care Home

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. 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 17, good governance. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Further work was needed to ensure staff worked together effectively on all floors at the home. We found some shortfalls in oversight and the changes of manager and recent absence of a manager had impacted on the overall governance and stability of the service. The regional and district manager told us they were committed to improving the culture of the service, improving communication and ensuring the employment of the right manager to move the service forward.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. The provider had employed 4 different managers at the service in the year prior to our assessment. This had impacted on the quality of the service provided.

Action taken to ensure a management presence in the service meant steps had been taken by providing regional management presence and visible within the service. This led to a more positive, compassionate and listening culture. However, there continued to be a lack of experienced leadership from team leaders.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of the whistle blowing process and different forums available to them so they could speak up if something was wrong. Staff confirmed they were actively encouraged to raise concerns with managers and felt confident their voices would be heard.

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. There was an open and inclusive atmosphere in the service. Many care staff were positive about working at Marham House Care Home and would recommend it as a place to work. There were policies and procedures in place to ensure the provider met their legal obligations to staff and work towards a fair and inclusive culture. Staff were supported to complete equality and diversity training.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At the time of our assessment the service did not have registered manager in post. The regional manager had based themselves full time at the service to provide consistency and continuity to people, their relatives and staff. The provider had recognised there were improvements needed, and an action plan had been put in place. However, we found the providers systems and processes used to monitor the quality and safety of the service required further improvement to ensure all areas of the service were monitored effectively on a daily basis ensuring robust oversight was in place as highlighted in this report.

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. Collaboration with external stakeholders included healthcare professionals such as the GP Practice, community nursing and the local authority to support people’s care.

Whilst the provider had systems in place to focus on continuous learning, innovation and improvement across the organisation these were not always effective at Marham House Care Home. They did not always deliver equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.