CQC report explained · a nursing home
What the CQC found at Mabbs Hall Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Care plans and risk assessments did not always give staff enough guidance. Inspectors also found gaps in repositioning and fluid records, medicines recording problems and concerns about staffing levels.
- Effective?
- Good
- This key question was not inspected during this visit, so its previous rating carried over.
- Caring?
- Good
- This key question was not inspected during this visit, so its previous rating carried over. Inspectors did observe kind and caring staff.
- Responsive?
- Requires improvement
- This key question was not inspected during this visit, so its previous rating carried over.
- Well-led?
- Requires improvement
- Audits had identified some problems, but progress was slow. Care records were not always kept up to date, and three manager changes since January 2023 had affected oversight.
What inspectors found, August 2023
Mabbs Hall Care Home was rated Requires Improvement; inspectors found risks in care planning, medicines, staffing and management.
This was an unannounced inspection on 20 June and 10 July 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines records, recruitment files and quality checks.
The home was not always safe. Some care and risk plans lacked clear instructions. Records showed gaps in repositioning and fluid monitoring. Medicines were mostly given as prescribed, but there were problems with labelling, stock records and recording a strong pain relief medicine. Inspectors also found there were not always enough staff to meet people's needs, and some staff had difficulty communicating in English.
The home was rated Requires Improvement overall, with Safe and Well-led both rated Requires Improvement. This was a change from the previous Good rating, published in April 2019. The inspection found kind staff, effective safeguarding and infection control, but the provider had not made improvements quickly enough.
Safeguarding
Inspectors found effective systems to protect people from abuse. Staff understood how to recognise and report concerns.
“People were protected from the risk of abuse because the provider had effective safeguarding systems in place.” from the report
Infection control
Inspectors were assured that infection prevention systems, cleaning, protective equipment and outbreak arrangements were effective.
“Many relatives told us that the care home bedrooms and bathrooms were kept spotlessly clean.” from the report
Kind staff
People appeared comfortable with staff, and inspectors found that staff understood people's preferences and wanted to provide good care.
“People looked comfortable and had a good rapport with staff supporting them.” from the report
Choice and legal safeguards
The home was working within the principles of the Mental Capacity Act. Necessary liberty safeguards were in place and related conditions were being met.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place” from the report
Care plans and risk records
seriousSome care and risk plans did not explain clearly enough how staff should meet people's needs or reduce risks. Gaps in repositioning records could increase the risk of skin damage and pressure wounds.
“People's care plans and risk assessments did not always give staff all the information they needed on how to safely care for people.” from the report
Medicines records
seriousSome external medicines had missing labels or opening dates. Pain relief patch stocks did not match records, and one strong pain relief medicine was being given but was missing from the person's medicines profile.
“Stock levels did not match records and the 'body map' did not always have a record of where on the body these had been applied in line with best practice guidance.” from the report
Staffing and communication
seriousPeople and relatives reported rushed care and lengthy waits for call bells or help to use the bathroom. Inspectors also found that communication was difficult with some staff who did not speak English as a first language.
“Some people told us staff were not always able to spend quality time with them and were rushed at times and that response times to call bells being used could be lengthy.” from the report
Management oversight
seriousThe home's systems for checking quality and reducing risk were not robust. Problems identified by audits were not corrected quickly, and care records were not regularly updated.
“Whilst audits in place had identified some of the shortfalls we found at this inspection, progress on making the necessary improvements was slow.” from the report
- 01What has changed in care plans and risk assessments since the inspection, particularly for repositioning, fluids and nutrition?
- 02How do you now check that external medicines are labelled, dated and within their safe use period?
- 03How many staff will be available on each shift, and how will you prevent delays in answering call bells?
- 04How do you make sure staff can communicate effectively with my relative?
- 05What progress has been made on the action plan, and how will you show that improvements are being sustained?
This was a focused inspection of Safe and Well-led; the ratings for Effective, Caring and Responsive were carried over from the previous inspection. This explanation was written from the published report of 11 August 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, September 2020
Inspected but not rated; inspectors found good infection control arrangements during a targeted visit.
This was an announced, targeted inspection on 25 August 2020. It looked at infection prevention and control during the coronavirus pandemic, rather than all aspects of care.
Inspectors were assured that the home was managing visitors, social distancing, admissions, protective equipment, testing, hygiene and possible outbreaks safely. They also found that people's health was reviewed weekly by the clinical lead and GP.
The home was inspected but not rated overall, and the Safe question was also marked inspected but not rated. This report therefore does not provide a full CQC rating for the home.
Regular health reviews
Everyone living in the home had their care and support reviewed weekly. The report says this helped health concerns to be identified and managed promptly.
“Everybody living in the service has their care and support reviewed weekly by the clinical lead and GP.” from the report
Controlled visiting
Visitors did not enter the building. Visits were planned in the garden or courtyard, and the home was considering how visits could continue in worse weather.
“Visitors did not access the service building. Pre-planned visits took place in the garden or the courtyard.” from the report
Infection control
Inspectors were assured about the home's arrangements for protective equipment, testing, hygiene, admissions and managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Risk assessment for staff
The home had a specific assessment for staff at higher risk from coronavirus, including their level of exposure to the virus.
“There was a specific risk assessment for staff at high risk from Coronavirus.” from the report
Approach still being developed
minorInspectors signposted the home to resources to develop its approach. The report does not explain which parts needed further development.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01How did you arrange visits when outdoor visiting was no longer practical?
- 02What changes did you make after being signposted to resources to develop your infection control approach?
- 03How are residents' weekly health and care reviews recorded, and what happens when a concern is found?
- 04How do you identify and support staff who may be at higher risk from coronavirus?
- 05How do you manage testing, protective equipment and possible infection outbreaks now?
This was a targeted inspection of infection prevention and control, mainly under Safe, and it did not provide ratings for the other areas of care. This explanation was written from the published report of 3 September 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.
Every inspection of Mabbs Hall Care Home
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- August 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2020Inspected but not ratedSafe: Inspected but not rated
- April 2019Goodstayed GoodSafe: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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