Marigold House

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 service. This key question has been rated requires improvement. 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.

The service was in breach of the legal regulation in relation to governance. The provider had not always ensured their systems were effective or ensured oversight of quality, safety and management of risks.

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.

Leaders described inheriting cultural and practice issues within the service and recognised the need to rebuild expectations and standards. This included addressing performance concerns, improving accountability and promoting a more consistent approach to care delivery. Leaders were able to articulate a clear vision for the service and the improvements they wanted to achieve.

People were supported to maintain relationships, participate in meaningful activities and remain connected to their local community. There was evidence leaders promoted person-centred care and encouraged staff to focus on people's individual experiences and wellbeing. A staff member told us, “The residents make it a good day.” This meant although the culture continued to be developed, we found evidence leaders were working to create a more open and positive environment for people and staff.

Leaders were visible throughout the assessment process and engaged openly with feedback. Staff generally described leaders as approachable and willing to provide support when required. Leaders demonstrated an understanding of the challenges facing the service and were able to discuss improvements they had introduced. A relative told us, “If you notice a problem they're straight on to it.”

However, we identified concerns relating to safeguarding, care planning, risk management and oversight which had not been recognised through existing management arrangements. This reduced assurance that leaders always had effective oversight of the service and were consistently identifying concerns and driving improvements. In response to our feedback, leaders reviewed records, introduced additional monitoring arrangements and took action to strengthen oversight processes.

People, relatives and staff had opportunities to share their views about the service. Staff told us they felt able to raise concerns and discuss issues with leaders. There was evidence of resident meetings, staff meetings and other opportunities for feedback to be gathered and discussed.

The provider encouraged feedback and there was no evidence people, or staff were discouraged from speaking up about the quality or safety of care. A staff member told us, “I approached the manager to advise of issues which were taken to management and addressed appropriately.”

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. Staff did not raise any concerns in relation to workforce equality, diversity and inclusion.

The provider's systems and processes were not effective in assessing, monitoring and improving the quality and safety of the service. We identified safeguarding concerns which had not been recognised or escalated appropriately, care records which did not always accurately reflect people's needs and preferences, medicines and environmental concerns which had not been identified through audit processes, and risks which had not always been reviewed or acted upon appropriately. These concerns had not been identified or addressed through the provider's own governance systems. This meant there was an increased risk leaders did not always have accurate oversight of people's experiences, risks and outcomes.

Following our feedback, leaders reviewed records, strengthened oversight arrangements and introduced additional monitoring processes. However, these actions were not yet fully embedded, and we will check for sustained improvement at our next assessment.
 

The provider worked in partnership with relatives, healthcare professionals and the wider community to support positive outcomes for people. Records demonstrated involvement from GPs, district nurses, specialist services and other healthcare professionals when required to support people's health and wellbeing. Families were involved in care planning, reviews and important decisions about people's care.

People were supported to maintain meaningful connections within their local communities. The service had established links with local schools, community groups and external organisations which enabled people to participate in a wide range of activities and events. Examples included intergenerational projects, visits from local schools, community outings, therapy animal visits, participation in local events and opportunities for people to engage with groups and organisations outside of the home. These partnerships helped reduce social isolation and supported people's wellbeing and quality of life.

Some of the provider's systems and processes required further embedding to ensure their effectiveness in assessing, monitoring and improving the quality and safety of the service. This was evidenced by concerns identified during our assessment which had not been recognised through the provider's own governance arrangements. These included concerns relating to safeguarding, care planning, risk management and oversight. The provider was open and receptive to feedback throughout the assessment and took immediate action to review records and strengthen oversight arrangements.

There was evidence the provider had implemented a range of quality assurance processes, including audits of care records, medicines, incidents, accidents, falls and the service environment. Leaders also demonstrated how learning and information were communicated across the organisation through staff newsletters. This included updates from services, examples of good practice, learning from incidents and a dedicated feature highlighting activities and developments at Marigold House. A staff member told us, “Lessons learnt are written down on [electronic care planning system] and shared with staff.”