Marigold Nursing 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.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to 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 legal regulation in relation to good governance. Lack of leadership and management oversight had failed to identify shortfalls in people’s care, placing them at potential risk of harm.

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The culture of the home was not currently person-centred. People’s basic care needs were not being met adequately. The provider had not created a learning culture to ensure people received good care.Some relatives told us the quality of care had deteriorated. A relative told us, “There has been a steady decline in standards since [registered manager] left.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively,or they did not always do so with integrity, openness and honesty. Leadership and management arrangements had been ineffective in maintaining the previously outstanding care from the last inspection. There was currently no registered manager on site when we visited the home. There had been various interim arrangements in place, whilst a new manager was recruited. A staff member said, “We need a manager for support and advice.” A new manager had been identified and was awaiting checks to be completed to enable them to start work. A relative commented, “I have no idea who is in charge. I have never seen [interim manager].”

People did not always feel they could speak up and that their voice would be heard. Although people and relatives felt able to speak up, they told us general communication with management and staff had deteriorated. Staff knew about the whistle blowing procedure and confirmed they felt confident to speak up if needed. A staff member said, “If I have any issues, I can tell the nurse or deputy manager. Everything is sorted out really well.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Some staff told us changes were made to their working arrangements without proper consultation, which had impacted them adversely.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider’s quality assurance (QA) systems were ineffective in monitoring the service to ensure people received the care they needed, and lessons were learnt.

There was a lack of management oversight from the provider. Provider QA checks were not done consistently and lacked detailed information about findings and proposed action to address issues. Potential risks to people’s safety were not managed effectively to ensure people remained safe.

Checks and audits had failed to identify and address the significant shortfalls we found during the assessment. This included addressing shortfalls in the environment, care records and responding to people’s needs. Although, many of these were addressed during the inspection, the provider had not been proactive in resolving these in a timely way. Audits lacked detailed analysis to provide reassurance about action taken to keep people safe and identify lessons learnt. Care records were not always accurate or fully completed, such as oral health care records

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. The lack of consistent management oversight since December 2024 meant the quality of care had deteriorated over time.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The provider lacked effective systems to monitor and mitigate risks associated with people’s safety, and to learn lessons. There was very limited analysis of accidents, incidents and safeguarding concerns to allow lessons to be learnt and improve people’s care.