CQC report explained · a nursing home
What the CQC found at Malvern House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection prevention arrangements, including PPE, testing, admissions and outbreak planning. They found gaps in visitor plans, formal staff risk assessments and the cleaning records for high-risk areas.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Inspected but not rated; inspectors found strong COVID-19 infection controls, but some records and cleaning information were incomplete.
Inspectors visited the home on 11 February 2021. This was an announced, targeted inspection during the coronavirus pandemic. They looked at infection prevention and control measures. The home provided nursing and personal care for up to 22 older people, with 19 people living there at the time.
Inspectors found the home clean, hygienic and uncluttered. There were suitable arrangements for COVID-19 testing, self-isolation, visitors, PPE and managing an outbreak. Families were supported to keep in touch through windows, an open fire exit, telephone and IT.
Some records were not complete. There were no formal written visitor plans in people's care plans. A staff member's increased COVID-19 risk was known but not recorded in a formal risk assessment. The cleaning schedule did not clearly show regular enhanced cleaning of high-risk areas such as door handles.
The service was inspected but not rated. This was not a full inspection of all five areas of care, so the report does not provide an overall Good, Requires Improvement or Inadequate rating.
Clean environment
Inspectors found the home clean, hygienic and uncluttered. Cleaning of communal areas had been increased when housekeeping staff were on duty.
“The home was clean, hygienic and uncluttered in appearance.” from the report
COVID-19 testing and PPE
The home had testing arrangements for people and staff, and had plentiful PPE available. Staff received updated infection control information and training.
“Plentiful supplies of personal protective equipment (PPE) were available in the home.” from the report
Contact with families
The home provided ways for people to see or speak with family during lockdown, including windows, an open fire exit, telephone and IT. Permitted indoor visits had infection control measures.
“People were supported to speak with their friends and family using IT and the telephone as necessary.” from the report
Visitor plans were not written down
needs fixingThe home did not have formal individual visitor plans in people's care plans. This meant social contact needs were not fully recorded.
“However, there were no formalised written individualised visitor plans as part of the care plan to make sure social contact needs were met.” from the report
Staff risk information was not formally recorded
needs fixingThe manager knew which staff members might be at increased risk from COVID-19, but this information was not recorded in a formal risk assessment.
“However, this information was not recorded in a formal risk assessment.” from the report
Cleaning records were unclear
needs fixingThe cleaning schedule did not clearly show that high-risk areas, such as door handles, were cleaned more than once a day on a regular basis.
“It was not clear from the cleaning schedule that enhanced cleaning of high-risk areas, such as door handles, took place more than once a day on a regular basis.” from the report
- 01Have individualised visitor plans now been added to each person's care plan?
- 02How are the COVID-19 risks for staff members formally assessed and recorded?
- 03How often are door handles and other high-risk areas cleaned, and where is this recorded?
- 04What evidence can you show that the home's COVID-19 testing, PPE and outbreak arrangements remain up to date?
This was a targeted inspection of infection prevention and control measures during the coronavirus pandemic; it was not a full inspection of all five areas of care and the service was not rated. This explanation was written from the published report of 10 March 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.
What inspectors found, February 2019
Rated Good; inspectors found safe, kind and personalised care, with strong leadership across the home.
Inspectors made an unannounced visit on 24 January 2019. They spoke with people living in the home, relatives, staff and a visiting healthcare professional. They observed care and looked at care records, medicines records, staff files, training records, rotas and other records.
The home was caring, safe and well organised. Inspectors found enough staff, safe medicines arrangements, personalised care plans and good links with healthcare professionals. People were treated with kindness and respect, and could make choices about their daily lives.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. This was the first inspection since the home re-registered as a new legal entity in February 2018.
Kind and respectful staff
Inspectors saw calm, patient and discreet care. People and relatives spoke positively about staff's kindness and compassion.
“Staff were patient and discreet when providing care for people.” from the report
Enough staff
Staffing levels were adjusted when people's needs changed. Inspectors saw call bells answered promptly and care provided in good time.
“There were enough staff on duty to meet the needs of people who lived at Malvern House.” from the report
Personalised care
Care plans described people's individual needs, wishes and preferred support. They were reviewed monthly or when needs changed.
“Care plans were personalised to the individual and gave clear details about each person's specific needs and how they liked to be supported.” from the report
Safe medicines
Staff were trained to give medicines, records were completed and checks of controlled medicines matched the stock held.
“There were safe arrangements in place for the administration, storage and deposal of medicines.” from the report
Strong management
The management team was visible and supportive. The home used feedback, meetings and regular audits to monitor the service.
“There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.” from the report
Inspectors raised no specific concerns in this report.
- 01How have staffing levels changed since the inspection, and how do you adjust them when people's needs change?
- 02How will you make sure my relative's care plan reflects their current needs, wishes and communication requirements?
- 03How are medicines that are given when needed monitored and reviewed?
- 04What activities are currently available for people with different interests, abilities or health needs?
- 05How do relatives contribute to care reviews and decisions about the running of the home?
This was an unannounced inspection covering all five CQC areas and both the premises and the care provided; it was the first inspection since the service re-registered in February 2018. This explanation was written from the published report of 15 February 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 Malvern House
Each visit the CQC has published, newest first, back to the day the home was registered.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2018
Registered with the Care Quality Commission on 16 February 2018.
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.
Weigh the report against the rest
Fees, photos and reviews from families
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What to check when you visit
10 live-in carers within about two hours of Cornwall
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,200 a week. 8 can care for a couple. 12 years' experience on average.
“He had been a little anxious before she arrived, but has since stated that he would be very happy for her to care for him again”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.