Marlborough Court 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.

People using the service were protected from abuse and avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had effective systems for reporting and learning from incidents. Staff understood their responsibilities regarding safeguarding and knew how to report concerns. Staff told us the management team maintained an open culture where they felt confident reporting concerns, contributing to the overall safety of the service. When incidents occurred, investigations were conducted, and appropriate actions were taken to prevent recurrence.

People were supported with transitions between services. The staff worked closely with other professionals to make sure they had information about people’s needs. People had healthcare passports that were shared with health and social care professionals when required. These provided a brief medical history, information relating to episodes of recent illnesses and GP visits, next of kin, weight history, mobility needs, risk assessment summary for all areas of risk and information relating to ‘Who I Am’ and how best to support the person.

The provider had procedures in place to protect people from abuse. A person using the service told us, “I feel safe as the carers come running if I press my buzzer. They are very caring towards me.” A relative told us, “I feel my loved one is very well looked after and is in a very safe environment. I have no concerns.” Another relative commented, “It's a great weight of my mind that my loved one is there; they are safe and well cared for.”

Staff told us they had received training on safeguarding adults from abuse, and they felt confident any concerns they raised would be managed appropriately. Training records confirmed staff had received training on safeguarding.

The service had a whistle blowing procedure in place. This was displayed within the service and included contact details of the registered manager and regional manager along with the local authority and CQC. A staff member said, “I would report any concerns I had to the registered manager. I am very confident they would deal with it.” Another staff member told us, “I would tell the registered manager if I saw abuse, I would also report concerns to the local authority safeguarding team or the CQC if I needed to."

There were reporting systems in place, and management demonstrated a proactive approach to safeguarding. There was good oversight of safeguarding concerns and accidents and incidents. Records showed that appropriate actions were taken by staff where required following any concerns and adverse events.

Risks to people’s safety and wellbeing were assessed and planned for. A relative told us, “I have been fully involved in my loved one’s care planning and have been involved in all decisions.” Another relative commented, “The home will ring me, and we discuss things, queries I or they may have regarding my loved one.”

People received safe care from staff who understood and managed risks effectively. The service maintained robust safety systems and processes that protected people from harm. For example, clinical risk assessment, medicines management, care plan audits, pressure audits and bed mattress checks. Risk assessments were regularly updated and guided staff in delivering appropriate care. However, we noted there were gaps in some people’s turning and nutritional intake charts. We drew this to the registered managers attention. They took immediate action to make sure these were completed consistently by staff. The registered manager told us they would continue to discuss this issue during the daily meetings held with staff.

Staff told us they followed care plans and risk assessments. A staff member told us how they supported people at risk of choking by observing them whilst they ate and making sure they were receiving appropriately thickened drinks. They advised us what they would do if the person was in difficulties. They also advised us they made sure people deemed at risk of falls were supervised and those people nursed in bed had sensor mats in place and (where people could not use call bells) hourly checks were carried out to make sure they were safe.

The design of the premises met people's needs. We saw appropriate signage to aid people’s orientation such as lounge, bathrooms and toilets. Memory boxes were displayed outside people’s bedrooms with important information about them such as their work history, what football team they supported and their country of origin.

People had their own bedrooms which they personalised with furniture and belongings. People had equipment they needed to help keep them safe, such as hoists, wheelchairs, walking aids, and bath and shower equipment. These were regularly checked to make sure they were safe to use.

The provider assessed and maintained the environment and equipment used. For example, fire alarm system, portable appliances, gas safety and water legionella testing. People had individual emergency evacuation plans in place which highlighted the level of support they required to evacuate the building safely in the event of an emergency. Checks and audits were also carried out on the call bell system and regular fire drills were conducted. The kitchen had received a food hygiene rating of 4 from the Food Standards Agency in June 2025.

There were gardens with suitable furniture that people could enjoy in warm weather. On the first day of our assessment, we noticed that the gates between the garden and a local pathway were not locked. This was a safety risk as some people may leave the premises without staff being aware. We drew this to the registered managers attention who ensured the gates were immediately repaired.

People told us their family and friends were able to visit them regularly. There were no restrictions placed on visitors, and we observed relatives, friends and people visiting the service freely throughout our assessment.

We observed there were enough staff deployed throughout the service to meet people’s needs when required. A relative told us “I feel there are enough carers when we have been to visit. There is always someone about and both the nurses and the carers can give me information about how my loved one is doing.” A staff member told us, “We can be very busy in the mornings, but I feel we have enough staff to meet people’s needs. The registered manager will make sure we have enough staff.”

Robust recruitment procedures were in place. Recruitment records included proof of identification, application forms with employment histories, employment references, occupational health and right to work in the UK checks. Nursing staff’s National Midwifery Council Pin numbers were also sought and recorded. We saw evidence that Disclosure and Barring Service (DBS) checks had been carried out. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

People felt staff had the right skills and knew how to support them, one person told us, “The staff know what they are doing, they are very helpful.” We saw a training matrix which indicated that staff had completed training in areas such as living with dementia, falls prevention, oral health, fire safety, basic life support, infection control, medication administration, moving and handling, safeguarding adults, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Training was provided face to face and using online training programs. Nursing staff has also completed training on medication administration, diabetes, end of life care, venepuncture and dysphagia. We saw a supervision and appraisal matrix that confirmed that staff received regular supervision 5 times a year and an annual appraisal.

Staff told us they had received training and support in relation to people’s individual needs. They told us they received regular supervision, and they were up to date with training the provider considered was mandatory. One staff member told us, “If staff are not up to date with training they are not allowed to work here. The face-to-face training I had on dementia was helpful. I learned how to interact and how to care for people with living with dementia. We had a specialised trainer, and I was able to ask questions on how to care for the residents."

There were systems in place to help prevent and control infections. We observed the service was clean throughout. We observed the housekeeping team cleaning on each floor of the service. They showed us a cleaning schedule they followed a every day. A person using the service told us, “The home is clean, and they clean my room at least once a day.” A relative commented, “I feel it is a clean and tidy home and my loved one’s room is clean and tidy.”

The provider employed a housekeeper and housekeeping staff to oversee cleaning and laundry. The housekeeper told us they were responsible for making sure staff followed safe infection prevention procedures. They showed us cleaning schedules for each unit, dining rooms, toilets and bathrooms and communal areas. They carried out weekly infection control and housekeeping audits and a deep clean was carried out each month or when needed. They told us the registered manager had made improvements at the service, cleanliness and the environment was better, for example there was non-slip flooring instead of carpet which was easier to keep clean.

Staff were provided with personal protective equipment (PPE) when needed. We saw they wore this appropriately. A person using the service told us, “The staff wear PPE when they are in my room.” Training records confirmed that all staff had received training on infection control.

People received their medicines safely and as prescribed. A person using the service told us, “The nurse in charge gives me my medication. It is when I need it.” Medicines were administered by trained staff who had completed up-to-date medication competency assessments. Staff followed the home's medication policy and received annual refresher training. Medication rounds were generally unhurried, and staff were observed checking MAR (Medication Administration Record) carefully before administering medicines.

Medicines were stored securely in locked cabinets and medication trolleys within the home. Regular audits of medication practices were carried out by the management team. Where issues were identified, action plans were put in place and followed up to completion.

Medication Administration Records (MARs) were mostly completed accurately, with clear signatures and codes for non-administration where appropriate. A small number of gaps were identified where the reason for omission was not recorded. PRN (as required) medication protocols were in place, but some needed more detail to guide staff on when to administer these medicines. We drew this to the registered managers attention. They took immediate action to remind the team to always document reasons for any omissions of medicines. They also worked with their clinical team to update them with clearer guidance on when to administer PRN medicines.