CQC report explained · a nursing home
What the CQC found at Mansfield Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Inspectors found testing, protective equipment, social distancing and safe admissions in place. They were not fully assured about the infection control policy, touch-point cleaning or visitor precautions.
- Effective?
- Good
- Not assessed in this targeted inspection.
- Caring?
- Good
- Not assessed in this targeted inspection.
- Responsive?
- Good
- Not assessed in this targeted inspection.
- Well-led?
- Good
- Not assessed in this targeted inspection.
What inspectors found, March 2021
Inspected but not rated; inspectors found good COVID-19 precautions but gaps in infection control policies, cleaning and visitor checks.
This was an unannounced, targeted inspection on 11 February 2021. It followed concerns about infection prevention and control. Inspectors looked at how the home managed these risks.
The home had testing for residents and staff, supplies of personal protective equipment, staff training and social distancing measures. Technology was being used to help residents keep in touch with their families while visitors were not entering the home.
Inspectors were not assured that the infection control policy was up to date. More cleaning of touch points was needed, and visitor questionnaires and temperature checks had not been routine. The provider made some changes during or after the inspection.
The home was inspected but not rated. This means the inspection did not give a quality rating for the service or a full rating across the five areas.
Testing
Testing was in place for residents and staff. Daily temperature checks were increased to twice a day.
“Testing has been increased since the COVID-19 outbreak. Daily temperatures were being taken; however, these were increased to twice daily to meet government guidance.” from the report
Protective equipment
There were enough supplies of protective equipment, placed around the home for staff to access easily.
“There were sufficient supplies of personal protective equipment (PPE), which were placed around the home for easy access.” from the report
Staff training
Staff had training on using protective equipment and changing it between residents. The manager said regular checks were carried out.
“Staff had received training in wearing their PPE and the importance of changing between each person.” from the report
Keeping in touch
Technology and telephone calls were being used to help residents keep contact with their families while visits were not taking place.
“Technology was used to support calls to family thought this method or the telephone.” from the report
Policy not up to date
needs fixingInspectors were not assured that the infection prevention and control policy reflected current guidance. They asked the provider to review it.
“We were not assured that the provider's infection prevention and control policy was up to date.” from the report
Cleaning of touch points
needs fixingRoutine cleaning took place, but cleaning of frequently touched surfaces did not continue after domestic staff had finished work. The provider reviewed the cleaning schedule.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises. Additional touch point cleaning was required.” from the report
Visitor checks
needs fixingVisitors had not routinely completed a questionnaire or had their temperature checked on arrival. The provider introduced these measures.
“On arrival visitors had not been routinely asked to complete a questionnaire to support track and trace, the provider implemented this procedure along with a temperature check.” from the report
- 01Has the infection prevention and control policy been updated in line with current guidance, and when was it last reviewed?
- 02How often are touch points cleaned now, including after domestic staff have finished their hours?
- 03Are all visitors now asked to complete a questionnaire and have their temperature checked on arrival?
- 04How are staff competency checks for using and changing PPE recorded?
- 05When will the visitors' pod be available for use again?
This was a targeted inspection of infection prevention and control under the Safe area; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 20 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, August 2019
Mansfield Manor Care Home was rated Good overall, but inspectors found medicines and risk management were not always safe.
This was an unannounced planned inspection on 17 June 2019. Inspectors reviewed care records, medicines, staffing, accidents, complaints and quality checks. They spoke with people living at the home, relatives and staff, and observed care.
The overall rating was Good. Effective, caring, responsive and well-led were all rated Good. People generally had positive experiences, felt safe and were supported by kind staff who knew them well.
Safe was rated Requires Improvement. Inspectors found problems with medicines records and storage, risk assessments, food and fluid monitoring, and care records. Some staff also lacked important training, although training had been planned.
The home had already identified many issues and acted quickly after the inspection. It sent action plans covering medicines, risk assessments, care records and staff training. The previous overall rating in 2016 was Good, but caring fell from Outstanding to Good and safe fell from Good to Requires Improvement.
Kind and personal care
People and relatives consistently described staff as kind, caring and respectful. Staff knew people's preferences and supported their independence.
“People were supported by staff who were kind and caring.” from the report
End of life support
Families gave very positive feedback about end of life care. People's wishes were discussed and recorded, and families were involved in planning.
“People were provided with caring and compassionate support at the end of their lives.” from the report
Responsive management
The management team had identified many issues and acted quickly in response to the inspection. It prepared action plans to address the shortfalls.
“During and after our inspection the management team were responsive to our feedback and took swift action based upon this.” from the report
Activities and community links
People were offered a range of activities and some attended local community groups. The home also supported people's religious and cultural needs.
“People were provided with opportunities for meaningful activity.” from the report
Medicines safety
seriousInspectors found inconsistent medicine storage, recording and administration. Records did not always show that creams or skin patch checks had been completed.
“There was a risk people may not receive their medicines as prescribed.” from the report
Risk assessments
seriousSome risks, including dehydration, weight loss, bedrails and people's behaviour, were not fully assessed or clearly recorded. This could leave staff without enough information to provide safe support.
“People were not always protected from risks associated with their care and support.” from the report
Care records
needs fixingSome staff said they did not read care plans, and records did not always show that people had received the care they needed.
“This meant there was a risk people may not get the support they needed.” from the report
Staff training
needs fixingTraining records showed gaps in dementia training and training to support people whose behaviour posed a risk. Further training had been booked.
“Further work was required to ensure staff had the training they needed to provide safe and effective care.” from the report
CQC notifications
needs fixingThe provider had not always told the CQC about allegations of abuse as legally required. The manager said this would be corrected.
“The provider had not always notified us of specific events at the home, as they are legally required to.” from the report
- 01Have all the medicine storage, recording and administration problems found in June 2019 now been fixed?
- 02How are you currently checking risks such as dehydration, weight loss, bedrails and behaviours?
- 03How do you make sure staff read each person's care plan and complete care records properly?
- 04Have all staff completed dementia training and training on supporting behaviour that may pose a risk?
- 05What has changed about staffing levels at night and in the morning since staff raised concerns?
This was an unannounced planned inspection that considered all five CQC questions and both the premises and the care provided. This explanation was written from the published report of 2 August 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 Mansfield Manor Care Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Goodstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2016GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- May 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 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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