Marsden Heights Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Responsive – this means we looked for evidence that the service met people’s needs. We received feedback that people received care which was person-centred and the service involved people and relatives in decision making. Reasonable adjustments were observed throughout the home. People were involved in decision about their care and treatment and the running of the home. People and relatives knew who to speak to if they had a problem and were generally confident that staff were approachable and responsive to concerns.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff confirmed that they felt leaders had the experience, capability and integrity to ensure that the organisational vision was delivered, and risks were well managed. A staff member said, “If I have an issue, I know I can go to any of the seniors, deputy manager or registered manager. I don’t feel uncomfortable asking for support.” Leaders were knowledgeable about issues and priorities and could access appropriate support and development in their role. The deputy manager and registered manager confirmed the provider encouraged them to develop their own skills and competence, offering regular support.

High-quality leadership was sustained through safe and effective recruitment. We saw evidence of robust recruitment processes for the current registered manager, including reference and DBS checks. Disclosure and Barring Service (DBS) checks provide information including details of convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Training details were shared which confirmed a range of topics had been covered. Meetings between the provider and the Nominated Individual took place covering various aspects of the business and quality. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Staff were encouraged to raise concerns and were confident their voices were heard. Staff told us that regular team meetings took place and action was taken in response to issues raised. A staff member said, “Meetings are held every 1 to 2 months. Yes, changes are made. The manager is responsive to feedback.” When asked how the service is monitored for closed cultures, the registered manager advised unannounced spot checks had recently been introduced following information of concern. They added, oversight was good due to themselves and deputy managers being visible and working alongside staff at the service.

Staff and leaders were prompted to act with openness, honesty and transparency. The provider had a whistleblowing policy, and posters explaining what to look out for and how to raise concerns were prominently displayed in the reception area. Staff were prompted to raise concerns during team meetings and the provider sought their views via annual surveys.

Staff told us they felt they were treated fairly, and that morale was improving since extra staff had been employed. A staff member said, “We have a good team at the moment, they all seem to be happy and enjoying work.” The deputy manager advised they ensured staff received fair and equitable treatment by being approachable to staff and offering support, especially those facing difficulties in their home life.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for their workforce. Flexible working and equal opportunities policies ensured the service took staff’s employment rights into account and the staff handbook clearly explained topics such as wages, sick leave and holiday entitlement.

The registered manager spoke of the different quality assurance systems, but acknowledged improvements were required to some areas. Staff understood their roles and responsibilities, and those of senior staff and managers, and confirmed checks on safety and the quality of care were completed. A staff member said, “Deputy’s do medication audits and the registered manager does spot checks and other checks.” The deputy manager advised the provider allowed appropriate resources to improve standards and enable the service to meet people’s needs.

Incidents were not always submitted to external organisations as required; and the integrity of some data was not robust or used to effectively monitor and improve the quality of care. For example: we found incomplete and inconsistent information in several people’s records. Whilst audits and checks were in place, these governance systems were not always effective. Issues with the environment, processes to manage risk and management of medications had not been identified by the provider prior to this assessment.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.