Marlborough House

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

We identified 3 breaches of regulations The registered manager did not always ensure safe care and treatment, and risk management. The management of medicines needed improvement. The provider and the registered manager needed to improve recruitment processes to ensure people were not at risk of harm from being supported by unsuitable staff. The registered manager did not always ensure all incidents and accidents were reported, to ensure necessary actions were taken, and any lessons learned noted with themes or trends identified. People were protected from abuse, neglect and discrimination. Relatives felt their family members were kept safe. Staff described their responsibilities to raise concerns and report incidents or allegations of abuse and felt confident issues would be addressed appropriately. The registered manager and the staff team were working with the local authority to investigate safeguarding cases and provided support to address any issues. The registered manager used dependency tool to review staffing numbers. We observed kind and friendly interactions between staff and people. Relatives made positive comments about the staff and the care they provided.

.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives were encouraged and supported to raise concerns. One person said, “I am happy, staff are lovely people…staff will help if I ask.” Relatives agreed they were kept informed if any incidents or accidents happened to their family member in the service. They felt any incidents or accidents were dealt with openly and preventative measures were put in place as needed. Relatives said, “[The person] has had far fewer incidents than in the last few years, they have an alarm and they keep [the person] safe. They [are] open and transparent” and “Only 2 days ago, [the person] started to choke a little bit…I got the carers and they pressed the emergency button and virtually immediately all the staff arrived. The response from ALL staff members was amazing!”

The registered manager told us how they oversaw and monitored the service to ensure safety for the people and relatives and staff team. The service was using an online systems where incidents and accidents, complaints, and other events were logged. The registered manager explained how they looked at these for any themes and identify any improvements areas or what worked best for the people. The registered manager told us about daily, weekly and monthly meetings, observing practice and keeping records regarding incidents, accidents, risks and any changes. The registered manager told us they had an open-door policy and encouraged staff to bring any issues or concerns to them. They said incidents, accidents, issues were discussed to identify any lessons learned, as well as themes and trends to support risk management. Staff told us they supported people to raise any concerns and remain as safe as possible. Staff told us how to report and record incidents and accidents, any other issues and take action to ensure people’s safety. Staff told us they discussed these events within meetings with managers to review it and identify any lessons learned, improvements or changes to people’s care. However, our evidence demonstrated the process of reporting and recording was not consistently understood and followed to support effective risk management.

There was a system in place for recording accidents, incidents, complaints and any concerns to take action. However, we reviewed people’s daily notes and identified incidences were not always recorded and logged for review and identify any further action to support people. For example, one person was found unresponsive during lunchtime, however this was not followed up in the daily notes and it was not recorded on the provider’s incident log. Another person found 2 pain patches applied and the senior staff did not report nor escalate this appropriately to the managers as per provider’s process. This issue was identified during our assessment and then the registered manager took action to address this. The registered manager did not always ensure there was a consistent process in place for recording, reviewing incidences and sharing learning with staff to ensure risks were mitigated and care plans updated to reflect any changes in people’s individual needs. There were some incidents where the duty of candour applied. The provider had a policy set out the actions staff should take in situations where the duty of candour would apply. People were supported to receive the required treatment and appropriate care. Whilst the provider ensured people and families were kept informed and updated, the specific steps taken to meet the duty of candour requirements were not always recorded. We discussed this and requirements of the regulation with the registered manager to ensure clear record keeping in the future. This would also ensure the provider acted in an open and transparent way with relevant persons in relation to the incidents.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were protected from abuse, neglect and discrimination. Relatives agreed their family members were safe with staff at the service. They said, “Oh yes definitely, [the person] seems happy and gets lots of attention, [the person] is clean and tidy” and “Yes, [the person] is safe living there, and is also free from abuse, neglect and harm.” A few people told us they were able to seek support from staff if they had any issues or worries. Relatives said they were able to contact or speak to staff or the registered manager if they needed to raise any queries or issues.

The registered manager told us about their responsibilities regarding safeguarding people and reporting concerns to external professionals accordingly. They took actions to investigate those to ensure it was addressed appropriately. The registered manager told us how they worked with staff to ensure people were supported to raise concerns when they did not feel safe and monitored or any changes in the safety of people. The registered manager and staff followed safeguarding systems, processes and practices to ensure people’s human rights were upheld and they were protected from discrimination. The registered manager added, “We always say to staff make sure all intervention, actions are recorded as you go along, and notifying senior staff straight away and always escalate. We tell the staff, if they ever concerned, come and get one of us and staff are very good at doing that.”

The registered manager shared information with the local authority and families, as well, in order to ensure transparency of the events and actions taken. The staff were encouraged to share any concerns with the manager or other senior staff they felt comfortable with. Staff explained how to recognise abuse and protect people from the risk of abuse. Staff told us how to report concerns at the service. Most staff told us how to report concerns to external authorities such as the local authority safeguarding team. They were confident the registered manager would act on any concerns reported to ensure people's safety. Some staff told us how they supported people to understand their rights, to feel safe and to receive care they needed.

During the visit to the service, we observed interactions between people and staff. People could seek support from staff and the managers at any time. Staff responded to people in a gentle, caring and kind manner, including when people became upset or anxious. Staff provided reassurance to people and helped them get back to their activities. Staff had an understanding of safeguarding and how to take appropriate action to ensure people were protected from abuse or harm. Professionals agreed the provider had appropriate systems, processes and practices to safeguard people from abuse. One professional added, “I have always found the staff to be very proactive in regards to any safeguarding concerns,” and “Yes, they have always raised any issues/concerns quickly”.

There were process and practice in place to report and ensure people were protected from abuse and neglect. The registered manager and staff demonstrated there was a commitment to taking timely action to keep people safe from abuse and neglect. The registered manager ensured concerns related to people or the service were shared openly and appropriately. Staff received safeguarding training and had a good understanding about how to protect people from different forms of abuse. This supported people being safeguarded from the risk of abuse and having their rights upheld.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The registered manager had made DoLS referrals, where appropriate for people living in the service to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.

People and relatives were informed and involved in making decisions about their care and support most of the time. Relatives and people were positive about the support and care people received. Relatives agreed the staff supported them and people to understand and manage any risks. One relative added, “[The staff] support [the person] by taking them in the wheelchair, in the bathroom there is a walking frame for support. They have been good assisting [the person] with mobility,” and “Yes they keep [the person] safe, sides on the bed; bed is lowered to the floor. Staff help [the person] and knows what [the person] can have.”

However, the evidence we have collected demonstrated people were not always protected from risks associated with their health, wellbeing and care.

The registered manager told us they worked together with staff to oversee and manage risks. They communicated with staff about people, their care, any changes and what action to take to address it. The registered manager told us people’s records were reviewed every month or when changes happened. They added, “The nurses review [risk assessments]. I would have a conversation about risks in a handover as well or part of [resident of the day review]. I ask daily if there was anything else we need to discuss. If anything is raised, we would discuss it, and then nurses would complete documents and record the information. They ask for my input if needed.” The registered manager told us the staff team supported people when they communicated their needs, emotions or distress. They said, “Talking about people’s presentation changes, becomes unwell…To ensure of support available but keep people safe. Always ask for help…as it can affect the resident.” They said people and any deteriorations were monitored and discussed daily with staff, to ensure timely response. Staff told us they had risk assessments and care plans to support people safely and effectively. Staff told us how they supported people’s needs when identifying potential risks, managing actual risks, and keeping these under review. Staff said, “All the team have a real focus on safety” and “Explain every task or procedure to the resident, talk them through diagnosis, medications, expectations. Ensure residents understand every measure and get them to understand and consent to each action.” Staff told us they shared information about people within the team on a regular basis, including if there had been any changes to risks and related assessments. Staff told us how they supported people when they were upset, distressed or anxious. Staff told us they did not use any types of restraint. The evidence collected demonstrated the registered manager did not always ensure clear and effective risk oversight and management.

We observed when people communicated their needs, staff were able to manage this in a positive way that protected their rights and dignity. We observed people were supported to move freely around the service and staff did not place any restrictions on them. Changes in people’s health or wellbeing were recorded and discussed during handover to agree further actions and support needed.

People’s care plans and risk assessments were not always clear about how to minimise and mitigate risks, promote choices and if staff were following the assessments. For example, after health professionals reviewed one person, part of the risk management was to encourage this person to have specific exercises. The staff did not record if these were completed with the person. Staff did not encourage the person to use the call bell to support risk mitigation of falls. Person’s risk assessments for falls and skin integrity did not describe meaningful information to support risk mitigation. Some people required a sliding sheet for repositioning but they were at times re-positioned by hand. This type of support was not part of care plans. Some people required transfer by hoist, however when we reviewed the daily notes, some people had been transferred using a standing aid, and it was not always clear if the appropriate slings had been used. We noted in one person’s care plan staff needed to reposition this person every 2-3 hours, however we noted at times this person was not re-positioned for 8 hours. Risk assessments were not consistently followed to ensure the individual needs of people were met. For example, one person’s risk assessment for choking and dysphagia noted the person had been reviewed by speech and language therapist (SALT) and required level 1 thickened fluid to mitigate risk of choking. We reviewed the daily notes and on multiple occasions this person was given ‘thin’ fluid consistency. This did not reflect the staff followed the risk assessments for this person to support them remain safe, and to reduce the risk of avoidable harm. This meant the registered manager did not always assess and review risks to the health and safety of people to ensure staff were following plans of care and risk assessments consistently. Lack of oversight did not always ensure sufficient action had been taken to mitigate identified risks.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Feedback regarding staffing numbers was mixed. Relatives mostly considered there were enough staff to support people in the service without them being rushed. Some relatives thought that staffing levels were a bit low. Relatives said, “During the week there is [enough staff], however the weekends are a bit quiet on the staff side” and “Yes, I think there is enough staff, but I think sometimes some staff aren’t as good as the main staff.” Another relative added, “[There is] enough staff and they are wonderful and so kind, and [the temporary] staff sometimes don’t know what to do.” People told us they did not always feel there were enough staff to meet their individual needs, and that “it takes [staff] a while to come” when call bells were ringing. Some people also told us they did not feel the provider made changes following feedback to management. Another person told us staff responded to the call bells but would only switch it off and inform them they would come back later. Relatives were positive about staff and the training and skills they had to provide specific and individualised care to their loved ones. Some relatives said, “Yes they do, they always seem to be very professional and in talking to me they are very reassuring, and I feel very confident in them” and “From what I have seen, I think [the staff] are trained and skilled. I know [the person] is medically better now, they have reduced the amount of medication [the person] is on. They are adept.”

The registered manager explained how they carried out recruitment processes. They showed us a dependency tool used to review staffing numbers and deployment. The registered manager worked with the staff team to help them and also observe practice at the same time. The registered manager told us about staff training to ensure there were enough skilled and experienced staff. Most staff told us they had enough staffing numbers however, some felt due to high people’s needs, the job was intense to ensure it was done effectively and safely. Most staff felt supported by the registered manager, senior staff and each other but some commented the staffing could be managed better. Some staff felt using agency staff would put pressure on the staff team to ensure continuity of care. Staff told us they had the training they needed to be able to support people well, and could request additional support or training if needed. Some staff noted they would prefer more face-to-face training and better upskilling regarding mental health, wound care and dementia support. Staff had support and supervision meetings to discuss their professional development needs and other matters. Some staff noted they would like more sessions as they did not feel they had many. Staff felt they could approach the registered manager or other senior staff for help and advice. Staff told us they worked as a team and supported each other to look after the people. Staff said, “It can be very busy, but we support each other well. My team are very good, like a family” and “It is a friendly home. I’ve always felt part of team. [The registered manager and deputy manager are] lovely, very hands on and you can speak if concerned about anything”. However, the evidence collected demonstrated the registered manager did not always ensure effective and safe management of staff so that people were not supported by unsuitable staff.

Staff were not always effectively deployed to ensure people received timely support. We observed staff were patient with people and were able to support people with their requests. We observed on a few occasions that communal area was left without staff presence, but it was for a short period of time. There was no negative impact to the people at that time. Staff were not always available when people needed help or support. When people’s call bell rang, staff did not always respond promptly. For example, one person was shouting for help, the call bell was ringing but we could not see any staff. We went to look for staff to attend the person. We observed how lunch time was managed. There were up to 3 different staff bringing food out to people, and after the food had been brought out, there was only 1 staff who was supporting 13 residents. The same staff was continuously coming in and out of the room to go and get things for people, such as their next food item, or napkins. Staff deployment did not always ensure staff could spend some individual time engaging with people during lunch time so that people had good dining experience. During our site visit, we observed people were involved in some activities but there was a lot of time spent when people did not do much either sitting in the communal areas or watching television in their rooms. Although staff engaged respectfully with people, but this could have been done more often to ensure a level of stimulation.

The registered manager and provider did not ensure the required information according to the regulation was gathered before staff started working at the service which put people at risk of being supported by unsuitable staff. In 5 staff files we found discrepancies with gathering information of full employment history and unexplained gaps, evidence from previous employments related to health and social care regarding staff's conduct and verifying the reasons for leaving. We found necessary Disclosure and Barring Service (DBS) checks were not always completed prior to staff commencing work at the service. We talked through some issues found and the regulation with the registered manager and administration staff. After the site visit, we provided the list of missing information, however, the registered manager did not provide evidence they obtained all required information. Staff completed a variety of training on topics the provider had determined was mandatory, and role dependant training to meet people's needs and ensure their safety. However, review of training matrix indicated not all staff were up to date or completed training topics. For example, there were people who had diabetes or a catheter however not all staff had such training. Duty of candour was noted mostly as ‘not applicable’ although policy indicated this should be included in refresher plans. Part of the lessons learned from one complaint, was for staff to complete training for responding to complaints, completing root cause analysis, effective documentation and communication. It was not clear if these topics were completed by the whole staff team. Staff should receive appropriate and timely training to enable them to support and care for people effectively and safely. When new staff started at the service, they had an induction, training completion and a period of shadowing experienced staff.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We could not be assured people’s medicines were managed safely at all times due to the number of issues we found with the process and records. One relative noted they were not always informed about changes of medication, but most relatives felt involved in supporting to manage people’s medicine. Relatives considered people’s medicine management was safe and done appropriately. They said, “Yes, we have been there [in the service] when [the person] has been given tablets and they are locked up in a medicine cabinet” and “[Medicine is] safe and appropriately administered. There was an issue with [one medication] and that is now sorted.” Senior staff supported people with taking their medicines in a calm and patient manner, ensuring people had enough time to understand the process and they had taken the medicines safely. Staff explained what the medication was to people before administering and observed them taking the medication. We noted staff also ensured people’s drinks were refilled prior to leaving their rooms after administering medication.

The registered manager told us people’s medications had been assessed and reviewed regularly including when changes happened. The registered manager noted they worked with staff and GP to review and oversee people’s medicine to ensure effective prescription. We spoke about ensuring people were also involved in reviews and decisions regarding their medicine as this was not always happening. The registered manager said they shared any updates with staff team to ensure they were following good practice and current guidance. The staff explained how they supported people when they were upset or in pain, and to establish if they needed ‘as required’ medication, including understanding any non-verbal cues indicating pain or discomfort. Some staff described how they supported people with emotional wellbeing and reported any issues to the nurses to provide further medical support. Staff who supported people with medicines, told us about the training they received and how they supported people to take medicine. We reviewed the clinical medication room and found fridge temperatures were monitored, and controlled drugs were recorded in a controlled drug book. Staff told us the controlled medicines were monitored and recorded weekly by two members of staff, including one nurse. However, we found some issues relating to management of medicine that did not reflect the feedback gathered from the management team and staff.

The registered manager did not ensure the management of medicine was safe. For example, we found 7 unboxed insulin pens for one person in the clinical room fridge that was not listed as current medicine. There was no documentation to support this was checked by a pharmacist to ensure the person and staff were safeguarded from any risks by using this insulin. One person had their medicine broken into four pieces. But it was not documented if a clinician or a pharmacist was asked to confirm this medicine was safe to be broken and administered in this way. The provider told us they did not use homely remedies. However, we found two items of homely remedies in one person’s medication box. The registered manager was not aware of these items. There was no evidence to ensure these homely remedies had been reviewed with a clinician prior to use. We found staff were applying emollients that were not listed items on people’s medication administration record (MAR) sheets. Provider’s policy described how the homely remedies should be managed and records kept for it. However, this process was not followed. Protocols for ‘when required’ (PRN) medicines were not always completed or reviewed. They did not always include detailed information regarding people’s non-verbal cues to ensure staff were able to identify their ailments to provide effective and timely treatment. PRN protocols did not always include details to help people manage their emotions, moods and distress effectively, and to ensure medication was used as the last resort. When people had multiple PRN medicines to manage one ailment, PRN protocols did not have enough details which to use first and ensure desired outcome for people. Plans of care did not always include clear information how to follow safe process for using a nebuliser, glucose gel or specific supplements. We found some medicine that no longer was in use but was not discarded.