CQC report explained · a nursing home
What the CQC found at Hallmark Maycroft Manor Luxury Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People said they felt safe and inspectors found suitable safeguarding, staffing, medicines and risk management arrangements. Infection prevention and control measures were also checked and inspectors were assured by what they found.
- Effective?
- Good
- Staff had relevant training and induction, and worked with healthcare professionals when needed. People were supported with food, drink, healthcare and decisions about their care.
- Caring?
- Good
- Inspectors observed kind and respectful interactions. People were offered choices, supported to remain independent and treated with dignity and privacy.
- Responsive?
- Good
- Care plans reflected people's needs, preferences and personal histories. The home offered varied activities, supported visits and recorded people's wishes about end-of-life care.
- Well-led?
- Good
- The provider used audits and feedback to monitor quality. People, relatives and staff spoke positively about the way the home was run, and staff described good teamwork and communication.
What inspectors found, November 2022
Rated Good; inspectors found kind, safe and personalised care, with no concerns confirmed from the issues that prompted the inspection.
The inspection was unannounced and took place on 28 September 2022. Inspectors spoke with people living in the home, relatives and staff. They also observed care and checked care plans, medicines records and other documents.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, were treated kindly and had enough staff to support them. Inspectors found medicines were managed safely, care plans were up to date and the home was clean.
The inspection was partly prompted by concerns about care delivery. Inspectors said they found no concerns with care delivery. The overall rating stayed Good, the same as at the previous inspection published in November 2019.
Kind relationships
People said staff were kind and felt relaxed with them. Inspectors also observed friendly relationships between people and staff.
“People were happy with the care they received, felt relaxed with staff and told us they were treated with kindness.” from the report
Safe medicines and risk care
Medicines records were accurate, medicines were stored securely and audits were completed. Risk assessments gave staff specific guidance for needs such as falls or choking.
“Their care plans contained comprehensive and specific details for staff on how to manage these risks.” from the report
Personalised support
Care plans included people's preferences, interests, religious beliefs and personal histories. Staff were reported to know people well.
“Individual person-centred care plans had been developed, enabling staff to support people in a personalised way that was specific to their needs and preferences” from the report
Activities and family contact
The home offered a varied programme of activities, including one-to-one time for people who stayed in their rooms. Relatives were able to visit.
“There was a varied range of activities on offer which included, music, arts and crafts, quizzes, exercise, reminiscence sessions and visits from external entertainers.” from the report
Quality monitoring
The provider used audits, meetings and surveys to monitor the service and identify improvements. Staff described good teamwork and communication.
“The provider undertook a range of quality assurance audits to ensure a good level of quality was maintained.” from the report
No registered manager in post
minorThere was no registered manager at the time of the inspection. The general manager was in the process of registering with the CQC.
“At the time of our inspection there was not a registered manager in post.” from the report
Recent staffing shortage
minorOne staff member said the home had been short of staff a couple of months earlier. Inspectors found staffing was sufficient and safe at the inspection.
“We were a bit short a couple of months ago, but all is good now.” from the report
- 01Has the general manager now registered with the CQC, and who is legally responsible for the home while this is being completed?
- 02How do you assess daily staffing levels when people's needs change or staff are absent?
- 03How will you manage my relative's specific risks, such as falls, choking or poor nutrition?
- 04How will you involve my family member and us in reviewing their care plan?
- 05What activities and one-to-one support would be available if my relative preferred to stay in their room?
This was an unannounced inspection covering all five CQC questions, including infection prevention and control; it was prompted partly by concerns about care delivery, which inspectors said they did not confirm. This explanation was written from the published report of 8 November 2022 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, November 2019
Maycroft Manor rated Good; inspectors found kind, safe and well-managed care, with improvements since the previous inspection.
Inspectors visited without warning on 23 and 24 October 2019. They observed care, spoke with people, visitors and staff, and reviewed care records, medicines, recruitment files, training and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, supported and treated with kindness. Inspectors also saw respectful relationships between people and staff.
The home had improved its medicines management and quality checks since the previous inspection. At the last inspection, Safe and Well-led were Requires Improvement. Effective, Caring and Responsive remained Good.
Kind and respectful care
People described staff as kind and said they felt relaxed and safe. Inspectors saw friendly relationships and respectful support.
“People were happy with the care they received, felt relaxed with staff and told us they were treated with kindness.” from the report
Personalised support
Care plans recorded people's preferences, routines, interests and religious needs. Staff were observed offering choices and promoting independence.
“Detailed individual person-centred care plans had been developed, enabling staff to support people in a personalised way that was specific to their needs and preferences” from the report
Improved medicines checks
The home had introduced regular medicines audits and checks of stock and records. Inspectors found medicines records accurate and medicines stored securely.
“This has been achieved through regular medication audits being carried out, and taking prompt action to address any problems, errors and issues identified.” from the report
Activities and relationships
People had a varied programme of activities, including music, crafts, exercise, trips and visits from entertainers. Visitors were welcomed.
“We saw a varied range of activities on offer which included, music, arts and crafts, quizzes, exercise, trips out to the local community and visits from external entertainers.” from the report
Inspectors raised no specific concerns in this report.
- 01How are medicines audited now, and how quickly are any errors, shortages or missed doses dealt with?
- 02How do you decide whether staffing levels are enough when people's needs change or staff are absent?
- 03How often will my relative's care plan be reviewed, and how will their family be involved?
- 04What dementia training and support do staff receive?
- 05How can residents and families raise a complaint, and how will they be told what action was taken?
This was an unannounced inspection of all five CQC questions; Safe and Well-led improved from Requires Improvement, while the other three ratings remained Good. This explanation was written from the published report of 21 November 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 Hallmark Maycroft Manor Luxury Care Home
6 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Hallmark Maycroft Manor Luxury Care Home →
- November 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Hallmark Maycroft Manor Luxury Care Home →
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Goodstayed GoodSafe: Good
- February 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- July 2014
Report published without a new overall rating.
- November 2013
Registered with the Care Quality Commission on 21 November 2013.
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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