CQC report explained · a nursing home
What the CQC found at Mais House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe recruitment, safe medicine procedures, suitable risk assessments and effective infection control.
- Effective?
- Good
- This key question was not inspected during this visit. Its previous rating was used to help calculate the overall rating.
- Caring?
- Good
- This key question was not inspected during this visit. Its previous rating was used to help calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected during this visit. Its previous rating was used to help calculate the overall rating.
- Well-led?
- Good
- Inspectors found an open and supportive management culture, regular audits and opportunities for people, relatives and staff to give feedback.
What inspectors found, May 2023
Rated Good; inspectors found safe, well-managed care, but some care plans and records were not kept up to date.
This was an unannounced inspection on 4 and 6 April 2023. One inspector reviewed records, the building, medicines and infection control. They spoke with 15 people, staff, visitors, a relative and health professionals.
Safe and well-led were both rated Good. Inspectors found enough trained staff, safe medicine practices, suitable risk assessments, a clean home and systems for learning when things went wrong.
The management team was described as open and supportive. People and relatives were able to give feedback and staff said they felt supported. However, some care plans needed updating and there were inconsistencies in records.
The overall rating stayed Good, as it was at the previous inspection published in October 2018. The other three areas were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Enough trained staff
Staffing levels were based on people's needs. Call bells were answered promptly and people said they did not have to wait for support.
“There were enough staff to support people safely.” from the report
Safe medicines
Medicines were stored, given and disposed of safely. Staff had the training and competence needed to administer them.
“Medicines were stored, administered, and disposed of safely.” from the report
Open management
People, relatives and staff described the management as approachable and supportive. Feedback was collected and used to improve the home.
“The management team were open and transparent and welcomed feedback from people.” from the report
Learning from incidents
The home recorded and reviewed incidents, complaints and safeguarding concerns to identify lessons and reduce the chance of problems happening again.
“Incidents were recorded and analysed to determine the cause and identify changes that would prevent a re-occurrence.” from the report
Care records needed updating
needs fixingSome care plans did not reflect people's changed needs. Audits had identified this, but the updates had not yet been completed.
“It had been identified but not progressed.” from the report
Inconsistent records
needs fixingInspectors found inconsistencies in some people's records. These were corrected during the inspection and the report says risk was reduced.
“There were inconsistencies in people's records which were addressed immediately and risk was mitigated.” from the report
- 01How quickly are care plans updated when a person's needs change?
- 02What checks make sure information is consistent across all care records?
- 03What were the previous ratings for Effective, Caring and Responsive, which were not assessed during this visit?
- 04How will you show families that the care-record shortfalls have stayed corrected?
- 05How are relatives involved in care reviews and changes to care plans?
This was a focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 20 May 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, October 2018
Rated Good; inspectors found safe, kind and responsive care, with some care-record improvements still needed.
This was an unannounced comprehensive inspection. Inspectors spoke with people living at the home, relatives, staff and health professionals. They observed care, checked parts of the building and reviewed care plans, medicines, staff records and other documents.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable training and good access to health professionals. People were treated with kindness, involved in decisions and supported to keep relationships, independence and interests.
The home had previously been rated Inadequate and placed in special measures in 2015. It later improved to Requires Improvement. This inspection found that improvements had been made and sustained, so the overall rating changed to Good.
Some care records were not always consistent or as person-centred as they could be. These issues were identified and corrected or being worked on during the inspection, and inspectors found no negative impact on the care people received.
People felt safe
People and relatives said they felt safe. Inspectors found that risks, safeguarding concerns, accidents and medicines were managed through established systems.
“People told us they felt safe living at Mais House.” from the report
Kind and respectful care
Inspectors saw warm and compassionate interactions. Staff knew people well and supported privacy, dignity and personal choices.
“We observed and heard that people were treated in a kind and positive manner and there was a warm and friendly atmosphere throughout the home.” from the report
Good health support
People were referred to health professionals when their needs changed. Staff followed guidance about conditions such as swallowing difficulties and diabetes.
“They respond quickly when a health problem is noted and work well with us.” from the report
Activities and family links
People could choose from group and individual activities, outings and special events. The home supported visits and relationships with families and friends.
“Activities at Mais House were planned and tailored to meet peoples' preferences and interests as much as possible.” from the report
Improved leadership
The home had strengthened its quality checks and acted on feedback. Inspectors found that the previous concerns about quality monitoring had been addressed.
“At this inspection we found improvements had been made and the provider was now meeting the previous legal breach.” from the report
Some care records were inconsistent
needs fixingInspectors found inconsistent recording in three care plans. These records were amended and updated during the inspection, but record keeping remained an area the home wanted to improve.
“We found some inconsistent recording within three care plans and these had been identified by the clinical lead and were amended and updated during the inspection process.” from the report
Diabetes plans could be more detailed
needs fixingThe report says diabetic care plans could be more person-centred and informative. The home planned to develop them further when its new care-plan system was introduced.
“The clinical lead had identified that the diabetic care plans could be more person centred and informative” from the report
End of life records needed updating
needs fixingOne end of life care plan did not fully show how care had been adjusted. This was addressed during the inspection, including reminders about monitoring pain and offering food and fluids.
“The documentation had not fully reflected that care had been adjusted for this stage of their life.” from the report
- 01How do you check that care plans are accurate, consistent and updated when people's needs change?
- 02How are diabetic care plans made person-centred, and what information would staff follow if blood sugar levels change?
- 03How do you record and review changes in care for people receiving end of life care?
- 04What improvements have been made since the new computerised care-plan system was introduced?
- 05How do you monitor staffing levels and call-bell response times now?
This was an unannounced comprehensive inspection of all five CQC questions, following earlier concerns; the report contains conflicting years for one inspection date. This explanation was written from the published report of 25 October 2018 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 Mais House
5 rated inspections over 7 years: the service has improved, from Inadequate to Good.
- May 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- September 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2016Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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