CQC report explained · a nursing home
What the CQC found at Maesbrook Nursing Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2023
Maesbrook Nursing Home was rated Requires Improvement; inspectors found staffing, fire safety and management checks needed attention.
This was an unannounced focused inspection on 5 October 2022. Inspectors spoke with 11 people, 12 relatives and 9 staff. They reviewed care plans, recruitment files and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that staffing levels did not always meet people's needs promptly. They also found weaknesses in fire and electrical safety checks and in the systems used to identify and address problems.
There were some positive findings. People received medicines on time, the home was clean, and staff had access to protective equipment. Personal risks were recorded and staff knew how to support people at risk of dehydration.
This focused inspection looked only at Safe and Well-led. The other key question ratings were not reassessed and the overall rating changed from Good at the previous inspection to Requires Improvement because of this inspection's findings.
Medicines
Inspectors found that medicines were given safely and on time. Audits were completed and medicine errors were investigated.
“People received their medicine from staff who were trained in safe administration.” from the report
Personal risk support
Care records included several types of personal risk assessment. A dedicated team had also been introduced to help people at risk of dehydration.
“The staff knew who had been assessed as at risk of dehydration and were able to give them additional support” from the report
Clean environment
Inspectors were assured that the home was promoting safety through its layout and hygiene practices.
“We were assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Partnership working
The provider had worked with outside organisations, including a local university and Public Health England.
“The provider could demonstrate they had built partnerships with other agencies.” from the report
Not enough staff
seriousPeople and relatives reported delays when they needed help. Inspectors saw people waiting and found that staff were not always deployed effectively.
“People were not always supported by enough staff to ensure their needs were met in a timely manner.” from the report
Fire and electrical safety
seriousImportant property safety checks were not consistently up to date. The fire service had also raised concerns that all fire risks were not yet fully addressed.
“The 5-year electrical wiring certificate was significantly out of date.” from the report
Weak management checks
seriousThe provider did not have effective oversight of staffing risks, property risks or some people's concerns. This was a breach of the governance regulation.
“The governance processes in place were not adequately identifying risk or concern with in the service.” from the report
Limited feedback and communication
needs fixingPeople and relatives said they had too few opportunities to discuss care or influence how the home was run. Meetings were planned to restart.
“People and their relatives consistently told us they did not always have an opportunity to share their feedback on care” from the report
Infection-control restrictions
needs fixingSome staff were not wearing masks correctly. Relatives also felt that visitor booking and testing arrangements went beyond national guidance.
“We were somewhat assured that the provider was using Personal Protective Equipment (PPE) effectively and safely as we observed some staff not wearing the masks correctly.” from the report
- 01How many staff are now scheduled on each shift, and how do you make sure people are not left waiting for help?
- 02What evidence can you show that the fire risks identified by the fire service have been fully addressed?
- 03When was the latest electrical wiring check completed, and were any further actions required?
- 04How can residents and relatives give feedback, and how are concerns followed up?
- 05What has changed since the inspection to monitor the effect of staffing levels on accidents, falls and people's care?
This was a focused inspection of Safe and Well-led, with infection prevention and control included under Safe; the other key questions were not inspected and their previous ratings carried over. This explanation was written from the published report of 12 January 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, January 2021
Inspected but not rated; inspectors were largely assured about infection control, but found gaps in quality checks and staff COVID-19 risk assessments.
This was an announced, targeted inspection on 08 December 2020. It looked at infection prevention and control during the coronavirus pandemic, rather than rating the whole service.
Inspectors were assured that the home used PPE safely, followed shielding and social distancing rules, managed admissions, supported testing and had arrangements to prevent or manage outbreaks. People could see relatives through window visits.
There were two gaps. Infection control checks might not have been strong enough to find problems and make sure they were corrected. COVID-19 risk assessments for staff had not been documented. The provider said these issues would be addressed immediately.
The service was marked 'Inspected but not rated'. This report does not provide an overall rating or ratings for the other four questions.
Use of PPE
Staff used PPE in line with current guidance, including extra protection when providing personal care or supporting people who had tested positive for COVID-19.
“People were supported by staff who wore Personal Protective Equipment (PPE) in line with current guidance.” from the report
Safer visiting
The home used window visits and had a visiting policy to support contact with relatives while following social distancing guidance.
“People were supported to see their relatives through window visits to ensure compliance with social distancing guidance.” from the report
Outbreak planning
The infection prevention and control policy had been updated for COVID-19, and contingency plans were in place for future outbreaks or pandemics.
“Contingency plans were in place so the home was prepared in the event of future outbreaks or pandemics.” from the report
Checks may not find problems
needs fixingInspectors were not fully assured that the home's quality checks were strong enough to identify concerns and make sure action was taken. The provider said the audit process would be reviewed immediately.
“Whilst an up to date infection prevention and control policy was in place, we were not fully assured that quality checks currently in place would be robust enough to identify concerns and ensure appropriate action was taken to address them.” from the report
Staff risk assessments not documented
needs fixingCOVID-19 risk assessments for staff had not been recorded, so inspectors could not be fully assured that risks had been identified and reduced. The provider said these assessments would be completed immediately.
“Staff risk assessments regarding Covid-19 had not been documented so we could not be fully assured that risks to staff regarding Covid-19 had been identified and relevant action had been taken to mitigate risk.” from the report
- 01What changes were made to the infection prevention and control audit process after this inspection?
- 02How do you now check that audits identify problems and that corrective action is completed?
- 03Were COVID-19 risk assessments completed for all staff, and how are they kept up to date?
- 04How are visitors currently supported to see residents safely?
- 05What are the home's current arrangements for testing and managing a COVID-19 outbreak?
This was an announced targeted inspection of infection prevention and control practices during the coronavirus pandemic; it did not rate the overall service or the other four questions. This explanation was written from the published report of 23 January 2021 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 Maesbrook Nursing Home
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- April 2018Goodstayed GoodSafe: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 31 January 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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