CQC report explained · a nursing home
What the CQC found at Martin Hall Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable medicines arrangements and risk assessments. They also found a PPE shortfall, with four occasions where staff did not follow best practice, creating a risk of cross infection.
- Effective?
- Good
- This question was not inspected during this focused visit.
- Caring?
- Good
- This question was not inspected during this focused visit.
- Responsive?
- Good
- This question was not inspected during this focused visit.
- Well-led?
- Good
- Inspectors found audits, updated care plans, monitoring of issues such as falls and weights, staff meetings and arrangements for relatives to raise concerns.
What inspectors found, March 2021
Rated Good; inspectors found safe, well-managed care but staff did not always use PPE correctly.
Inspectors visited once on 10 February 2021, with 18 hours' notice. They spoke with staff and managers, reviewed care and medicines records, and later spoke with relatives and staff by telephone.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found enough staff, safe recruitment, suitable medicines arrangements, risk assessments and systems for reporting concerns and incidents.
The home was clean and had cleaning schedules and infection control training. However, inspectors saw four occasions when staff did not follow best practice for using personal protective equipment. They said this presented a risk of cross infection.
This was a focused inspection because concerns had been raised about staff practice. Inspectors looked only at Safe and Well-led. The other three ratings were not inspected, and no concerns were identified in the information held about them.
Enough trained staff
Inspectors found staff numbers were adequate and staff had training for their roles. Recruitment checks were also in place.
“During the inspection we saw no evidence of people waiting for care or of staff being unable to respond to people's needs.” from the report
Medicines managed safely
Medicines were administered safely and on time. Guidance was available for as-required medicines and appropriate advice had been sought for covert medicines.
“Medicines were administered safely and in a timely manner.” from the report
Clean environment
The home was clean and well maintained. Cleaning schedules and checks were being used.
“The home was clean and well maintained. Regular checks had been carried out to ensure cleaning regimes were effective.” from the report
Active management
The management team used audits and monitoring, acted on issues and updated care plans to reflect people's needs.
“Audits were in place and actions had been carried out following audits.” from the report
Good communication
Most relatives said communication was good and that they could raise issues. Staff also said they were supported and kept updated.
“Most relatives we spoke with felt the communication was good and they felt able to raise issues.” from the report
PPE was not always used correctly
needs fixingInspectors saw four occasions when staff did not follow best practice guidance for PPE. They said this presented a risk of cross infection, and the manager said the issues would be addressed.
“However, we observed four occasions when staff members did not follow best practice guidelines, this presented a risk of cross infection.” from the report
- 01What action was taken after inspectors saw four occasions when PPE was not used according to best practice?
- 02How do you check that staff are now using PPE correctly, especially during infection outbreaks?
- 03What were the findings of your recent audits and what actions remain outstanding?
- 04How are falls, people's weights and changes in care needs monitored and communicated to staff?
- 05How will you keep relatives informed and help them raise concerns or complaints?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and no new ratings were given for them. This explanation was written from the published report of 3 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, May 2018
Martin Hall Nursing Home was rated Good; inspectors found kind, safe care, but limited mealtime choice and a small reporting shortfall.
This was an unannounced, comprehensive inspection on 11 April 2018. Inspectors spoke with people living in the home, relatives and staff. They also reviewed care records, staffing, training and quality checks.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines arrangements, suitable care records and effective checks on the quality of care.
People were treated kindly and supported to make choices. They had access to healthcare, activities and help at the end of life. The report also noted that the home was under new ownership and that managers were changing, with registration arrangements still being completed.
Safe staffing and medicines
Inspectors found enough staff to provide safe care and found that medicines were administered and recorded safely.
“The provider had ensured there was enough staff on duty to provide safe care to people.” from the report
Kind and respectful care
Staff supported people calmly and respectfully, including when people were upset or needed help with personal care.
“People were treated with kindness and were given emotional support when needed.” from the report
Personalised care
Care plans included people's histories, preferences and changing needs. Activities were adapted to what people wanted to do.
“Care plans were regularly reviewed to make sure that they accurately reflected people's changing needs and wishes.” from the report
Quality checks
The home had checks covering areas such as falls, hygiene, health and safety and medicines. Action plans were used when problems were found.
“A system was in place for checking the quality of care and ensuring it was improved.” from the report
Limited choice at mealtimes
needs fixingThe report says there was no lunch choice shown on the menu. Staff offered alternatives if people did not like the meal, but some people felt there was insufficient choice.
“The people we spoke with told us they thought there was insufficient choice at mealtimes.” from the report
Care plan access was not clear to everyone
minorOne relative said they had discussed the care plan but had not seen it and did not know they could. Managers said they would consider how to improve involvement in care planning.
“I have not seen it, I wasn't aware that I could see it.” from the report
Two minor incidents were not initially reported
minorInspectors found that two minor incidents had not been notified to CQC. The home sent the notifications on the day of the inspection.
“We observed two minor incidences had not been notified to us.” from the report
- 01What choices are now offered at lunch and how are people's food preferences recorded?
- 02How can residents and relatives see, discuss and review the care plan?
- 03How many nurse vacancies are there now, and how will safe staffing be maintained while they are being filled?
- 04What changes have been made to ensure all incidents that must be reported to CQC are notified promptly?
This was an unannounced comprehensive inspection covering all five questions and the overall quality of the home; it was the first inspection for the location under the new provider. This explanation was written from the published report of 18 May 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 Martin Hall Nursing Home
2 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2021Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018GoodSafe: GoodWell-led: Good
- April 2017
Registered with the Care Quality Commission on 25 April 2017.
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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9 live-in carers within about an hour of Lincolnshire
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.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
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.