Marlborough Lodge

Updated 14 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection, we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors, a medicines inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Marlborough Lodge is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Marlborough Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people and 1 relative about people’s experience of care. We also spent time informally engaging with people with dementia and observing their experiences of care. We spoke with 5 members of staff, the registered manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also spoke with a further 4 members of staff and 4 relatives on the telephone. We contacted 1 professional by email for their feedback about the service.

We reviewed care records for 4 people including multiple medicines records. We also reviewed health and safety records, training data, 1 staff file for recruitment and staff supervision records, safeguarding log, incident and accident forms and quality monitoring records.

Updated 14 July 2023

About the service

Marlborough Lodge provides accommodation and personal care for up to 18 people. The service provides support to adults who are over and under 65 years, people living with dementia and mental health conditions, people who have a physical disability and people with sensory impairment. At the time of our inspection there were 11 people living at the service.

Accommodation is provided in one adapted building over two floors. People had their own room and there was a communal lounge, a dining area and communal bathroom facilities. People could access a garden from the ground floor.

People’s experience of using this service and what we found

Medicines management had improved, and people had their medicines as prescribed. Staff had been trained on administering medicines and their competence was regularly checked. We have made 1 recommendation about receiving and acting on medicines’ safety alerts.

Risks to people’s safety were in place and reviewed by management or senior staff. However, some risk management plans did not consider all factors which affect risk. For example, falls risk assessments did not review what medicines people were prescribed which might affect mobility. We also found some risk management plans were generic and not personalised. The provider assured us they would review these areas and identify appropriate improvements.

Monitoring to mitigate risks had improved. People at risk of developing pressure ulcers had air mattresses in place and staff were checking these to make sure they were safe. Some monitoring records had been filled in prior to care being delivered. The provider assured us this was a recording error, and they would give staff further training.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff had been recruited safely and there were enough staff available to respond to people’s needs. Staff had time to sit with people and did not appear rushed. People and relatives told us staff were kind and caring. Staff training had improved, and the induction process had been reviewed to make sure staff were well prepared for their work. Staff told us they were supported and felt able to share their views or raise concerns.

People and relatives told us the service was safe. Staff had been trained on safeguarding and all concerns had been shared with the local authority. Incidents and accidents were recorded, and management reviewed them to identify causes. Any learning was cascaded to staff in handovers, team meetings or supervisions.

People had choice of meals and were served hot food in a timely way. People and relatives told us the food was good and visitors were welcome to join people for a meal if they wished.

However, we found limited evidence of people being involved in their care and support. The provider told us it was not easy at times for people living with dementia to understand. We have made a recommendation about using different ways to involve people in their care planning.

People were referred to healthcare professionals in a timely way. Staff had a weekly visit from a healthcare professional to review health needs and staff could contact GPs easily. At the time of the inspection, nobody had any wounds needing care from community nurses.

There was a registered manager in post and we were told they were approachable. Quality monitoring systems were in place and helped to identify areas of improvement. The provider had a service improvement plan to log actions for improvements. There had been no complaints since the last inspection and no surveys had been carried out.

The provider had registered with the Information Commissioner’s Office (ICO) for using CCTV equipment in communal areas. The correct rating for the service was displayed at the service and on the provider’s website.

The home was clean, and staff used cleaning schedules to record all areas of the service were cleaned regularly. There was personal protective equipment available, and we observed staff using this in a safe way. Staff followed good infection prevention and control guidelines, for example, staff were not wearing inappropriate jewellery on their fingers.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 3 May 2023) and there were breaches of regulation. Following the inspection, we served the provider a Warning Notice and we imposed a condition on their registration. This condition was for the provider to send Care Quality Commission (CQC) a monthly action plan and summary of injuries and safeguarding incidents. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 11 January 2023. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from inadequate to requires improvement based on the findings of this inspection.

Recommendations

We have made 2 recommendations about receiving and acting on medicines alerts and involving people with dementia in their care.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect. The provider has a condition on their registration to submit a monthly action plan.