CQC report explained · a residential care home
What the CQC found at Marlborough Lodge
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines, safeguarding, staffing and infection control had improved. However, some risk plans did not include all relevant factors, and some monitoring records appeared to have been completed before care was delivered.
- Effective?
- Requires improvement
- Staff training, induction and supervision had improved, and people received timely healthcare support. Some weight-reducing diets and oral health needs were not fully explained in care plans.
- Caring?
- Good
- People and relatives described staff as kind and caring. Inspectors saw staff being attentive, reassuring and respectful, although people were not clearly involved in care planning.
- Responsive?
- Good
- People had choices, communication needs were recorded, and activities and local trips were available. Some care plans were generic rather than fully personalised.
- Well-led?
- Requires improvement
- Quality checks and the improvement plan had improved, and the registered manager was visible. However, the home's own checks had not identified records completed ahead of time.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found major progress after an Inadequate rating, but safety, effectiveness and leadership still need to become consistent.
Inspectors visited without notice on 19 and 20 June 2023. They spoke with people, relatives, staff and a health professional. They observed care and reviewed care records, medicines records, staff files, training records, incident records and quality checks.
The home had improved since the previous inspection. Medicines were managed safely, staff training had improved, there were enough staff, safeguarding concerns were referred properly, and the home was clean. People and relatives described staff as kind and caring.
There were still weaknesses. Some risk plans were generic or missed important information. Some records appeared to be completed before care was given. People were not clearly involved in care planning, and some care plans were not personalised. The home had no current breaches of regulation at this inspection.
The overall rating rose from Inadequate to Requires Improvement. The home had been in Special Measures, but it is no longer in Special Measures. The report says improvements need time to become established and last.
Safer medicines
Medicines were stored, administered and recorded more safely. Staff had training and regular checks of their competence.
“The provider had made the necessary improvements and medicines were now managed safely.” from the report
Kind staff
People and relatives said staff were kind and caring. Inspectors saw staff spending time with people and offering reassurance.
“We observed people being supported in a caring way. Staff were attentive to people's needs and knew them well.” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs. Training in moving and handling, fire safety, first aid and safeguarding had improved.
“There were sufficient numbers of staff available to meet people's needs and staff had been recruited safely.” from the report
Improved infection control
The home was clean, cleaning schedules were used, and staff used protective equipment safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Activities and outings
People took part in activities such as crafts, baking and gardening. Records also showed support for trips into the local town and local walks.
“We saw in people's records they had engaged in activities such as craft, baking, and gardening.” from the report
Risk plans were not complete
needs fixingSome risk plans were generic or did not include all factors that could affect risk. For example, falls assessments did not consider medicines that might affect mobility.
“However, some risk management plans did not consider all factors which affect risk.” from the report
Records completed too early
needs fixingSome monitoring records appeared to have been completed before care was delivered. The provider said this was a recording error and promised further staff training.
“Some monitoring records had been filled in prior to care being delivered.” from the report
Limited involvement in care planning
needs fixingThere was little evidence that people were involved in their care plans. Inspectors said different approaches should be used to involve people living with dementia.
“However, we found limited evidence of people being involved in their care and support.” from the report
Care plans were not always personal
needs fixingSome parts of care plans were generic and the same for everyone. The provider said these would be reviewed.
“However, we found some parts of the care plans were generic and the same for everyone.” from the report
- 01How will you make sure every risk assessment includes medicines and other factors that could affect a person's risk of falling?
- 02What checks now confirm that monitoring records are completed at the time care is provided, not beforehand?
- 03How will you involve a person living with dementia in their care planning and reviews?
- 04Which parts of my relative's care plan are personalised, and how often will they be reviewed with us?
- 05What monthly action plans and incident summaries are currently being sent to the CQC under the registration condition?
This was an unannounced follow-up inspection after the previous Inadequate rating, including infection prevention and control; Caring and Responsive remained Good from the last comprehensive inspection, while the other ratings changed to Requires Improvement. This explanation was written from the published report of 14 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2023
Marlborough Lodge was rated Inadequate and placed in special measures; inspectors found serious risks in safety, staff training, consent and management.
This was an unannounced focused inspection on 11 and 16 January 2023. Inspectors spoke with people, relatives and staff. They reviewed care records, medicines records, staff files, incident records, safeguarding information, fire safety records and quality checks.
Inspectors found widespread and serious problems. Risks were not properly assessed or managed. Medicines were not always handled safely. Staff used unsafe moving and handling techniques and lacked important training, including emergency evacuation training. Some safeguarding incidents were not reported.
People were not always supported in line with their wishes. Inspectors found problems with consent, covert medicines, CCTV, mealtimes and staff responses to people's needs. The home also lacked effective checks to identify and correct poor care.
The overall rating changed from Requires Improvement to Inadequate. Safe, Effective and Well-led were each rated Inadequate. The inspection did not assess Caring or Responsive, so those ratings carried over from the previous inspection.
Recruitment checks
The provider completed the necessary pre-employment checks for staff.
“Staff had been recruited safely following the provider completing necessary pre-employment checks.” from the report
Food quality
Inspectors said the food looked appetising, and people and relatives generally spoke positively about its standard.
“Food looked appetising and people and relatives told us the food was a good standard.” from the report
Visiting
Relatives said they could visit regularly and felt welcome. Visiting restrictions had improved since the previous inspection.
“Relatives we spoke with all told us they could visit regularly and were made to feel welcome by staff.” from the report
PPE storage
Inspectors found that personal protective equipment was stored more safely than at the previous inspection.
“At this inspection we found this had improved and PPE was stored in cupboards around the service.” from the report
Risk management
seriousCare records did not give staff enough personalised guidance about falls, diabetes, wounds, pressure ulcers, distress, food or fluids. Incidents were not always reviewed properly to prevent them happening again.
“Failing to assess and mitigate risks for people placed them at risk of avoidable harm.” from the report
Medicines
seriousSome as-required medicines lacked protocols. Opening dates and fridge temperatures were not consistently recorded, and a medicines stock discrepancy was not reported or investigated at the time.
“People who had 'as required' medicines in place did not have 'as required' protocols in place.” from the report
Staff competence
seriousStaff used unsafe moving and handling techniques. Training and induction did not show that staff were competent, and staff had not received adequate emergency training.
“Staff had not been provided with sufficient training to demonstrate competence in moving and handling people.” from the report
Safeguarding
seriousSome safeguarding incidents, including unexplained injuries, were not reported to the local authority. The provider also failed to report some required events to CQC.
“Incidents of safeguarding had not always been reported to the local authority safeguarding team.” from the report
Consent and dignity
seriousThe home could not show that decisions about covert medicines and restrictions were made lawfully and in people's best interests. Inspectors also saw staff disregard some people's requests and preferences.
“The provider was not working within the principles of the MCA.” from the report
Quality monitoring
needs fixingAudits had not found the problems identified by inspectors. The provider relied on CQC inspections to identify improvements rather than finding them through its own checks.
“The provider relied on CQC for their quality monitoring which is not appropriate or robust.” from the report
- 01What specific changes have you made to assess and manage risks such as falls, wounds, pressure ulcers, diabetes, distress, malnutrition and dehydration?
- 02How do you now check that staff are competent in moving and handling, first aid and emergency evacuation?
- 03What has changed in medicines management, including as-required protocols, opening dates, stock checks and fridge temperature records?
- 04How do you report and investigate safeguarding incidents and required notifications to CQC?
- 05How do you make sure decisions about covert medicines, CCTV and taking people out of the home follow consent and best-interest requirements?
This was an unannounced focused inspection of Safe, Effective and Well-led, with infection prevention and control also considered; Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 3 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Marlborough Lodge
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2023Inadequatedown from Requires improvementSafe: InadequateEffective: InadequateWell-led: Inadequate
- April 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- December 2018Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2017Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016
Registered with the Care Quality Commission on 29 February 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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