CQC report explained · a nursing home
What the CQC found at Mahogany Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from abuse and avoidable harm. Risks, staffing, recruitment, medicines and infection control were generally managed safely, although blood sugar testing equipment had not been checked as required and some care plans needed more detail.
- Effective?
- Good
- This question was not inspected during this visit. The report says ratings for questions not inspected were carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. Inspectors did observe caring and patient staff interactions.
- Responsive?
- Good
- This question was not inspected during this visit. The report says ratings for questions not inspected were carried over from the previous inspection.
- Well-led?
- Good
- Inspectors found that leadership had been unstable, with some staff supervision behind. A new manager was knowledgeable and proactive, and had started addressing the issues found.
What inspectors found, June 2022
Rated Good; inspectors found safe care and improving leadership, but some records and checks needed attention.
The inspection took place on 13 and 19 April 2022. Inspectors reviewed care records, risk assessments, staff recruitment files, medicines, audits and policies. They spoke with staff, people living at the home and family members, and observed care and a lunchtime meal.
The home was rated Good overall. Safe and well-led were both rated Good. Inspectors found that staff understood safeguarding and risks, staffing levels were based on people's needs, medicines were managed safely, and infection control arrangements were effective.
Leadership had been unsettled because there had not been a stable management team. Some staff supervision had fallen behind. A new manager had started making improvements, but inspectors said they would check whether these improvements lasted. Some medicines information and diabetes care plans also needed updating.
Safeguarding
Staff had safeguarding training and knew how to recognise and report suspected abuse or neglect.
“Staff had completed training in safeguarding. Staff we spoke with knew how to recognise signs of abuse or neglect and were aware of the procedure for reporting safeguarding concerns.” from the report
Safe medicines handling
Medicines were stored, administered and disposed of safely. Staff who gave medicines had training and yearly competency checks.
“Medicines were stored, handled, administered and disposed of safely.” from the report
Staffing and recruitment
Staffing was planned around people's needs. Recruitment checks were completed, and regular agency staff were used where possible to support continuity.
“Staffing levels were allocated in line with the home's dependency tool, which is a system to determine how many staff are required per day to support people safely.” from the report
Cleanliness and infection control
The home was clean and maintained well. Inspectors were assured that infection prevention arrangements were being followed.
“The home was clean and well maintained. Staff followed good infection control practices.” from the report
Blood sugar equipment checks
needs fixingEquipment used to test people's blood sugar was not being checked according to the manufacturer's instructions. The manager put the correct checking in place after the inspection.
“However, the equipment used to test people's blood sugar levels was not being checked as per the manufacturers instructions.” from the report
Medicines care plans
needs fixingInspectors recommended reviewing and updating medicines information and care plans. Diabetes plans needed clearer instructions about what staff should do when blood sugar results were outside the recommended range.
“We recommend reviewing and updating all people's medicines information and care plans to ensure they are up to date and accurate.” from the report
Management stability
minorThe home had experienced inconsistent leadership, and some staff supervision had fallen behind. A new manager had begun improvements, but inspectors wanted to see whether they were sustained.
“Leadership at the home had been inconsistent due to the lack of a stable management team.” from the report
Limited activities
minorSickness absence meant there was no regular activities coordinator, so activities were limited at the time of inspection. A new coordinator had been recruited and was due to start within the month.
“Due to sickness absence, there was no regular activities coordinator, which meant that activity provision at the home was limited.” from the report
- 01Have all medicines information and care plans now been reviewed and updated?
- 02How are diabetes care plans checked, and what instructions do they give staff when blood sugar readings are outside the recommended range?
- 03How often is the blood sugar testing equipment checked now, and who records those checks?
- 04Has the new management team kept staff supervision up to date?
- 05Has activity provision improved since the activities coordinator started?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the other ratings were carried over from the previous inspection. This explanation was written from the published report of 17 June 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, December 2019
Rated Good; inspectors found kind, safe and well-organised care, with improvements since the previous Requires Improvement rating.
This was an unannounced, planned follow-up inspection over three days in November 2019. Inspectors spoke with people living in the home, relatives and staff. They also observed care and checked care records, medicines records, recruitment files, audits and policies.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found clean and well-maintained premises, safe medicines management, enough staff during the inspection, thorough assessments and caring relationships.
The home had previously been rated Requires Improvement and had breached Regulation 17 about keeping accurate and complete records. Inspectors found enough improvement had been made, and the home was no longer in breach. The report also says a new manager was in the process of registering after the previous registered manager left.
Kind relationships
Inspectors saw staff treating people with kindness and respect. Staff knew people's wishes, likes and dislikes.
“We observed many caring and positive interactions between staff and people throughout the inspection.” from the report
Safe medicines
Medicines, including controlled drugs, were stored, given and disposed of safely. Staff had training and regular competency checks.
“We looked at how medicines were handled and found they were stored, administered and disposed of safely.” from the report
Clean environment
The home was clean, homely and maintained. Inspectors also saw infection control equipment being used.
“The premises were clean, homely and well maintained.” from the report
Personalised care
Care plans included people's needs, preferences and life histories. People and relatives were involved in planning and reviews.
“People's needs were comprehensively assessed and regularly reviewed.” from the report
Improved records
The home had acted on the previous inspection's concern about care records. Inspectors found enough improvement for the earlier breach to end.
“At this inspection we found enough improvements had been made and the provider was no longer in breach of this regulation.” from the report
Good oversight
Managers and the provider used audits, meetings and feedback to monitor the service and make improvements.
“The provider and registered manager followed governance systems which provided effective oversight and monitoring of the service.” from the report
Pressure when staff are absent
minorInspectors found enough staff during the visit, but a staff member said six carers could be a stretch and sickness increased the pressure. A relative also said agency staff might not know residents well.
“We can manage with six carers but it's a stretch, and then if someone rings in sick it takes its toll on everything.” from the report
- 01How do you keep staffing safe when a regular staff member is off sick?
- 02How do agency staff learn about each person's needs, preferences and risks before providing care?
- 03How will the improved care records be kept accurate and up to date?
- 04How will the new manager's registration with the CQC be progressed and who is currently responsible for the home?
- 05How will my relative and our family be involved in care plan reviews and decisions?
This was an unannounced follow-up inspection of the care provided and the premises, covering all five CQC questions and checking action from the previous inspection. This explanation was written from the published report of 21 December 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 Mahogany Care Home
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- June 2022Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015
Registered with the Care Quality Commission on 30 March 2015.
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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