During an assessment under our new approach
Marigold Nursing Home provides accommodation with nursing and personal care for up to 49 people. 30 people were living at the service when we visited, some of whom were living with dementia. This unannounced inspection was triggered due to anonymous concerns about poor care and a lack of management oversight. We visited the home on 20 and 21 August 2025 and found breaches of the regulations relating to person-centred care and good governance. Ineffective and inconsistent leadership and management oversight had led to significant shortfalls, placing people at risk of harm. Management support visits were not done consistently to monitor the service.
Potential risks to people’s safety were not being managed well, such as some risks not being assessed, items stored in stairwells, restricted areas not secured and infrequent fire drills. Maintenance issues were not addressed quickly. The provider acted to address some of these issues during the inspection but had not been proactive in resolving these earlier.
Areas of the home intended for people’s enjoyment were not accessible, as they were being used for storage. This included the multi faith room and the sensory room. The provider acted straightaway to clear the multi-faith room.
There was mixed feedback about staffing levels. The quality of interactions between people and staff was inconsistent. A staff member providing one to one support to a person was also supervising the communal lounge alone at various times during the day. New staff were not always recruited appropriately, as some checks were not recorded. The provider had not ensured all staff were suitably trained, as 2 staff had been employed for a significant period without having completed any mandatory training.
People did not experience a pleasant lunchtime due to a lack of organisation and staff not being fully aware of people’s specific needs. Menus displayed did not reflect what people were eating.
Although medicines were administered appropriately, medicines competency assessments for all staff had expired and were now overdue.
There were systems for managing and analysing incidents, accidents and safeguarding concerns. However, the analysis lacked detailed information of findings to identify and share lessons learnt.
Residents and relative’s meetings did not take place regularly.
Care plans contained appropriate information. However, daily records were not fully completed with gaps identified.
The provider’s quality assurance system (QA) required further improvement to prevent further deterioration in the quality of care. QA audits included very brief information, and no action plans were available to show how shortfalls were to be addressed.