CQC report explained · a nursing home
What the CQC found at Cubbington Mill
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2020
Cubbington Mill was rated Good; inspectors found kind, effective care but serious gaps in pressure-relief equipment checks and risk records.
Inspectors made an unannounced visit on 7 January 2020. They spoke with people, relatives, staff and a health professional. They also checked five people's care records and records about the running of the home.
The home was rated Good overall. Effective, caring, responsive and well-led were rated Good. Safe was rated Requires Improvement because records did not always show the support people received, and five of six checked pressure-relieving mattresses were set incorrectly.
People generally described kind and respectful care. Medicines, food and drink, activities and access to health professionals were managed well. The home had improved since the previous inspection and was no longer in breach of regulations, but the report said further work was needed on risk management.
Kind and respectful care
People and relatives said staff were kind, friendly and respectful. Inspectors saw staff supporting people without rushing them and respecting their privacy.
“Our observations showed staff were respectful and discrete when talking with people.” from the report
Safe medicines systems
The medicines records checked were correctly signed, and staff followed protocols for medicines given when needed.
“Medicine administration records (MAR) we checked, showed staff had correctly signed MAR's when medicines had been given.” from the report
Activities and social contact
People could take part in group and individual activities, including exercise, singing, crafts and visits from community groups.
“A variety of planned group and individual sessions helped engage people.” from the report
Improvement since the last inspection
The home improved its overall rating from Requires Improvement to Good. The provider was no longer in breach of the previous governance regulation.
“Improvements had been made since the last inspection.” from the report
Pressure-relief equipment
seriousFive of six mattresses checked were set incorrectly. This could have put people at unnecessary risk, even though no one had pressure sores at the time.
“We checked six mattresses and found five were incorrectly set.” from the report
Repositioning records
seriousRecords did not always show that people had been repositioned as required. One record suggested a person stayed in the same position for 18 hours despite a four-hour assessment.
“On one day, records showed a person had stayed in the same position for 18 hours, despite assessments stating every four hours.” from the report
Call alarm response
needs fixingSome people and relatives said staff sometimes turned off call alarms without always responding or returning. Managers agreed to review staffing and remind staff about the importance of sensor alarms.
“Some people and relatives gave us examples of when staff turned off call alarms and did not always respond or come back.” from the report
Care plan consistency
needs fixingSome care information was recorded in different places. Inspectors said this caused some confusion for staff and could affect consistent support.
“Some inconsistency in where certain information was recorded, gave staff some levels of confusion.” from the report
- 01How do you now check that pressure-relieving mattresses are set correctly for each person?
- 02How do you record and monitor repositioning, and how can relatives see that this is being done as planned?
- 03What has changed to make sure call alarms and sensor mats are used and responded to correctly?
- 04Where is each person's key care information recorded, and how do you prevent staff being confused by different records?
- 05What progress has been made with the immediate action plan sent after the inspection?
This was an unannounced planned inspection based on the previous rating and covered all five key questions, including the premises and care provided. This explanation was written from the published report of 8 February 2020 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, January 2019
Rated Requires Improvement; inspectors found kind care and enough staff, but gaps in wound care, medicines records and quality checks.
This was an unannounced comprehensive inspection on 4 December 2018, followed by an announced visit on 5 December. Inspectors spoke with people, relatives, staff and managers. They reviewed six care plans, daily records, medicines records and quality checks.
People said they felt safe and were treated kindly. There were enough staff, staff training was up to date, and people had access to health professionals. However, records and care plans did not always give staff enough information about risks, changing needs or skin problems.
The home was rated Good for Effective and Caring. It was rated Requires Improvement for Safe, Responsive and Well-led. The overall rating changed from Good to Requires Improvement because wound care and monitoring were not reliable, some medicines records were incomplete, and quality checks did not always lead to timely action.
Kind staff
People and relatives were positive about the staff team. Inspectors saw staff being patient, respectful and encouraging in many interactions.
“The care staff are kind and considerate…they take a personal interest” from the report
Enough staff
People said staff were available when they needed help and did not rush their care. Staff and managers also said staffing levels met people's needs.
“People said there were enough staff to meet their individual needs.” from the report
Training and consent
Training records showed staff had the skills and knowledge needed for care. Staff understood the importance of asking for consent and supporting people's choices.
“Training records showed staff training was up to date and staff were equipped with the skills and knowledge to look after those in their care.” from the report
Activities and social life
Activities were adapted to people's abilities and interests. The home involved families and local organisations in events and activities.
“People's activities were tailored to meet their needs.” from the report
Wound and skin care
seriousSkin checks and wound care records were incomplete. Staff knowledge about what to monitor and when to seek advice was inconsistent, and some dressings were not changed as advised.
“Out of the following 64 days prior to our inspection visit, only on 20 occasions was there evidence of any kind of intervention or monitoring of the sore.” from the report
Medicine records
needs fixingRecords for topical creams and patch medicines did not always show where, when or how much was applied. Medicine disposal records also lacked required signatures and dates.
“We found staff did not always consistently record some medicines such as topical creams.” from the report
Care plans and risk records
needs fixingSome care plans lacked detail about people's needs and risks. Reviews often used tick boxes rather than explaining changes or evaluating whether care was working.
“Care plans did not always support responsive care, especially when managing and responding to maintain skin integrity.” from the report
Quality checks
seriousManagement audits did not always identify problems or make sure action was completed. Provider audits had found some issues, but the problems continued.
“The systems used to monitor the effectiveness of the service were not effective and a lack of managerial scrutiny and oversight and adequate records meant we could not be confident actions were taken when improvements had been identified.” from the report
Inconsistent daily care
minorSome people were not always offered choices at mealtimes. Inspectors also saw inconsistent support with eating and some interactions that were task-focused rather than person-centred.
“This demonstrated that choice for all, was not always offered, or how this made that person feel.” from the report
- 01How are you now checking and recording wounds, red skin areas and pressure areas every day?
- 02How do you make sure pressure mattress settings are correct for each person and checked regularly?
- 03How are topical creams and patch medicines recorded, including where and when they were applied?
- 04What has changed in your audits and action plans since the inspection, and how do you check that actions are completed?
- 05How do you make sure each person's care plan records changing needs, falls risks, food and fluid targets, and advice from health professionals?
This was a comprehensive inspection covering all five questions, with an unannounced visit on 4 December 2018 and an announced return visit on 5 December 2018. This explanation was written from the published report of 22 January 2019 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 Cubbington Mill
3 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2020Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 15 February 2011.
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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