CQC report explained · a nursing home
What the CQC found at Mavern House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2022
Inspected but not rated; inspectors found good COVID-19 infection control and visiting arrangements.
This was a targeted inspection on 28 February 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and the effect of COVID-19 staffing pressures.
Inspectors found the home was taking steps to reduce infection risks. Visitors were screened and given protective equipment. Staff had training, protective equipment was available, and inspectors saw it being used safely.
The home supported contact with families through visits, telephone calls, video calls and social media. It also promoted essential care giver visits and offered staff wellbeing support.
The service was inspected but not rated. This was not a full inspection of all five areas of care, so the report does not give an overall quality rating.
Infection control
Inspectors were assured that the home had suitable measures to prevent and manage infection. Staff used protective equipment effectively and their competence was checked regularly.
“Staff competence and knowledge was regularly assessed.” from the report
Clean environment
The home had introduced extra cleaning measures, and inspectors found all areas of the home were clean.
“Additional cleaning measures had been introduced in the home. All areas of the home were clean.” from the report
Family contact
The home supported people to stay in touch with friends and family through visits and different forms of technology.
“The service was proactive in supporting people to maintain contact with friends and family, either through visits, or through the use of telephone and video calls and social media.” from the report
Visiting arrangements
The home promoted essential care giver visits and had a visiting policy in line with government guidance at the time.
“The provider's visiting policy was in line with government guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01What measures are currently in place to manage staffing pressures, and how do you check that these pressures are not affecting people's care?
- 02What are the current arrangements for family visits and essential care giver visits?
- 03How do you manage infection outbreaks, including testing, cleaning and the use of protective equipment?
- 04How do you support residents who cannot have regular visits to keep in contact with their families?
- 05How often is staff knowledge and competence in infection prevention and protective equipment checked?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 5 March 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, April 2020
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced inspection over 10 and 11 March 2020. Two inspectors and a specialist adviser visited the home. They spoke with people living there, relatives and staff, observed care and reviewed care plans, staff files and other records.
The inspectors rated all five areas Good: Safe, Effective, Caring, Responsive and Well-led. They found medicines were managed safely, risks were assessed, staff were trained and recruited safely, and people could access health professionals when needed.
People were treated with kindness and respect. Care was personalised, people's choices were supported, and there were detailed plans for end of life care. The home was clean, activities reflected people's interests and management systems were in place to monitor quality.
The previous rating was Requires Improvement, published on 3 July 2019, with one breach about staffing. The provider made improvements and was no longer in breach at this inspection.
Safe medicines and risk management
Medicines were received, stored, administered and recorded safely. Individual risks such as malnutrition, choking and pressure damage had been assessed with guidance for staff.
“Medicines were administered and recorded safely.” from the report
Kind and respectful care
People and relatives described staff as caring and respectful. Staff supported privacy, dignity and independence during personal care and daily activities.
“People were treated kindly and with respect.” from the report
Personalised support
Care plans described how each person wanted to be supported. People were helped to make choices, follow their interests and maintain important relationships.
“People's care plans were personalised and laid out the specific ways in which people would like to be supported.” from the report
Support for end of life
End of life plans recorded medical, social, religious and spiritual wishes. The home worked with health professionals to provide care that aimed to be pain free and dignified.
“People had end of life care plans in place, these included information about people's wishes regarding medical treatment as well as people's social, religious and spiritual wishes.” from the report
Improved staffing
The previous staffing breach had been resolved. Inspectors found the home used a dependency tool and reviewed call bell response times.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 18” from the report
Inspectors raised no specific concerns in this report.
- 01How do you use the dependency tool to decide how many staff are needed on each shift?
- 02What are the usual call bell response times, and what happens when responses are slower than expected?
- 03How would you support my relative's particular communication needs, including any hearing, language or sensory needs?
- 04How would you support my relative's nutrition, hydration and any risks such as choking or malnutrition?
- 05How would you record and follow my relative's wishes about medical treatment, relationships and end of life care?
This was an unannounced planned inspection covering all five key questions, following the previous Requires Improvement rating. This explanation was written from the published report of 18 April 2020 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 Mavern House Nursing Home
3 rated inspections over 3 years: the service has held its Good rating throughout.
- March 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- April 2020Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- December 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 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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