Marlborough House

Updated 26 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 22 March 2021 and was announced.

Updated 26 March 2021

This inspection took place on 16 and 17 November 2017 and was unannounced

Marlborough House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Marlborough House is registered to provide personal care and accommodation to up to 40 people who are frail or living with dementia. Accommodation is provided in a converted residential dwelling over two floors. At the time of our inspection 35 people were using the service.

Following the last inspection in June 2016 we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; Safe and Well led, to at least good.

At the last inspection we found that improvements were needed in obtaining a full employment history for new staff before they were employed At this inspection we found that improvements had been made in this area and a full history was available for all new and existing staff. We also found that action had not been taken when the systems in place had identified shortfalls. At this inspection we found action had been taken and improvements made.

People told us they felt safe living in the home. One person said, “I am happy living here and I feel very safe.”

There were systems and processes in place to minimise risks to people. These included a robust recruitment process and making sure staff knew how to recognise and report abuse. There were sufficient staff to safely meet the needs of people living in the home. People told us they thought there were plenty of staff and they did not have to wait long for their call bells to be responded to. Records showed that there were adequate numbers of staff available to meet the assessed needs of people in a timely manner.

Medicines were managed safely, securely stored, correctly recorded and only administered by on duty nurses and team leaders that were trained and assessed as competent to give medicines.

People received effective care from staff who understood their needs. Staff were able to tell us about people’s specific likes and dislikes. People told us they thought staff were well trained and understood them well. The registered manager and staff were very pro-active in arranging for people to see health care professionals according to their individual needs.

People and relatives told us that the food was good. We reviewed the menu which showed that people were offered a variety of healthy meals. We saw that food was regularly discussed and recorded at resident meetings.

All staff attended induction training before they started to work in the home. All staff said they had plenty of opportunities for training and the organisation also promoted dementia awareness training for all their staff.

People could enjoy a full programme of activities and staff had built up links with the local community to ensure people could stay in touch with organisations such as their place of worship and the local school.

People said they received care and support from caring and kind staff. Comments included, “The staff are all very caring, They listen to you and make you feel important.” And “They are all very nice very caring and very respectful.”

People received care that was responsive to their needs and personalised to their wishes and preferences. People were able to make choices about all aspects of their day to day lives.

People told us they could talk with staff and the registered manager if they wished to raise a concern. One person said, “I know who to talk to if I have a complaint but it has never come to that.”

People were supported at the end of their life to have a comfortable pain free death. Care plans showed people’s advance decisions were taken into consideration and acted upon.

There were formal and informal quality assurance systems in place to monitor care and plan on-going improvements. There were audits and checks in place to monitor safety and quality of care.

The service was well run by a registered manager who had the skills and experience to run the home so people received high quality person-centred care. The registered manager led a team of staff who shared their commitment to high standards of care and clear vision of the type of home they hoped to create for people.