Archived: Marlborough House

Updated 30 March 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This focused unannounced inspection took place on 2 March 2017. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our 6 and 7 July 2016 inspection had been made. We inspected the service against one of the five questions we ask about services: is the service Well-led? This is because the service was previously not meeting some legal requirements. This inspection was carried out by one inspector.

The provider had not completed a Provider Information Return (PIR), because we carried out this inspection before the required return date, therefore the registered manger was in the process of completing the form. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. Before the inspection we reviewed all the information we held about the service, looked at the previous inspection report and any notifications received by the Care Quality Commission. A notification is information about important events, which the provider is required to tell us about by law.

During the inspection we spoke to eight people, two staff, one visitor and the registered manager. Some people were not able to express their views clearly due to their limited communication. We observed interactions between staff and people. After the inspection we received feedback from one relative and one healthcare professional. We looked at three people’s care plans, associated risk assessments and guidance, audits and quality assurance information.

At our last inspection one breach of Regulation was identified.

Updated 30 March 2017

Care service description

Marlborough House provides accommodation and support for up to nine people who may have a learning disability and autistic spectrum disorder. Each person had a single room and there were two shower rooms and a bathroom, kitchen, dining room, lounge, activities room and ‘snug’. There are two small accessible gardens, which are totally paved, with seating and pots at the rear of the service. At the time of the inspection nine people were living at the service.

Rating at last inspection

At the last inspection on 6 and 7 July 2016, the service was rated Good overall and Requires Improvement in the 'Well-led' domain.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 6 and 7 July 2016. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach of Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014, Good governance. We undertook this unannounced focused inspection to check that the provider had followed their plan and to confirm that the service now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Marlborough House on our website at www.cqc.org.uk.

At this inspection we found the service remained Good overall and is now rated Good in the Well-led domain.

Why the service is rated Good

The service has a registered manager who was available and supported us during the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

There was an open and inclusive culture in the service, people using the service were fully involved and consulted about the care and support they received. People were at ease in the service, choosing where they wanted to spend their time and had a positive relationship with the staff team who understood each individual well.

Staff said they felt comfortable approaching the registered manager for help and support at any time. The registered manager had an open door policy and spent time with people to understand their personal needs well. The registered manager had taken action to address the shortfalls found at the previous inspection which were no longer a concern.

The registered manager and provider had well-embedded processes in place for auditing and monitoring quality. When areas needing improvements were highlighted, realistic timescales were implemented for action to take place. Any areas that had been identified as needing improvement were reviewed to ensure the quality of the service increased.

External stakeholders such as healthcare professionals gave positive feedback about the service and said the management communicated well with them about people’s needs. When people required input from other healthcare professionals the registered manager and staff team responded quickly offering the appropriate levels of support specific to individual needs.

Further information is in the detailed findings below