CQC report explained · a residential care home
What the CQC found at Merlin Court Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2021
Merlin Court Care Home had a targeted inspection and showed improvement, but its overall rating remained Requires Improvement and was not re-rated.
Inspectors visited unannounced on 3 March 2021. They spoke with three people, five staff members and reviewed incident, infection control, audit and meeting records.
The inspection found that required events were now reported to the CQC promptly. Incidents were reviewed, relevant professionals were told, and action was taken to reduce the risk of them happening again.
Inspectors were assured about infection control during the COVID-19 pandemic. The home had cleaning systems, PPE, testing, visitor screening and planned visits in place.
This was a targeted inspection, not a full review. The home had improved and was no longer in breach, but the previous overall rating of Requires Improvement stayed in place.
Incident reporting
Required notifications were being made promptly. Managers understood what had to be reported and records showed that incidents were reviewed and followed up.
“Records of incidents demonstrated notifications had been completed promptly when needed.” from the report
Infection control
Inspectors found systems to reduce infection risks, including cleaning, PPE, testing and visitor screening.
“We were assured that the provider's infection prevention and control policy was up to date.” from the report
Safe visiting arrangements
Visitors were screened and visits were booked in advance. A garden visiting room with screens had been created.
“The provider had built a garden visiting room with screens to keep people and relatives safe.” from the report
Learning from incidents
Incidents were shared with relevant health and social care professionals, reviewed and used to reduce the chance of recurrence.
“Incidents had been reviewed and action taken to minimise the risk of them happening again.” from the report
Overall rating still requires improvement
needs fixingThe home had improved, but the previous overall rating remained Requires Improvement because this inspection did not review the whole service.
“The overall rating for the service has not changed following this targeted inspection and remains requires improvement.” from the report
Limited inspection
needs fixingInspectors did not assess all five areas of care. This means the report cannot show whether the wider service was meeting standards in areas such as caring, responsive care or effectiveness.
“They do not look at an entire key question, only the part of the key question we are specifically concerned about.” from the report
- 01When will the next comprehensive inspection take place, and what is being done to improve the overall Requires Improvement rating?
- 02How do you check that all significant incidents are reported to the CQC promptly?
- 03What changes were made after the previous breach about reporting significant events?
- 04How are infection control, PPE, testing and visitor arrangements kept up to date?
- 05How do you review incidents and make sure actions taken have reduced the risk of them happening again?
This was an unannounced targeted inspection of specific Well-led concerns and infection prevention and control under Safe; the other areas were not assessed and the previous ratings carried over. This explanation was written from the published report of 7 April 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, November 2020
Targeted inspection, not rated; infection control was well managed, but the home remained in breach of a legal reporting requirement.
This was an announced targeted inspection on 10 and 17 September 2020. Inspectors checked whether the home had improved its reporting of serious incidents. They also checked infection prevention and control during the COVID-19 pandemic.
Inspectors found good arrangements for cleaning, visitors and personal protective equipment. Staff had training and enough equipment. People and relatives spoke positively about the cleanliness and infection control measures.
However, six serious injuries had not been reported to the CQC, and five had not been reported to the local authority. The home was still in breach of Regulation 18. This inspection did not give new ratings. The previous overall rating of Requires Improvement remained unchanged.
Clean environment
Inspectors found strong cleaning arrangements throughout the home. High-contact areas such as door handles and handrails were cleaned more often.
“There were robust cleaning arrangements in place, this included all areas of the home.” from the report
Infection control
Staff had PPE and training on how to use it safely. The home also had arrangements for changing uniforms and cleaning shoes.
“Staff had been given training on how to use PPE safely and were provided with the appropriate PPE to use.” from the report
Managed visiting
Visits were booked in advance, visitors were screened and PPE was provided. A visiting room with screens was cleaned after each visit.
“Visits were carefully planned and managed by the staff and had to be booked in advance.” from the report
Serious injuries not reported
seriousSix serious injuries were recorded and reviewed but were not reported to the CQC as required by law. Five were also not reported to the local authority at the time.
“We found six serious injuries that had not been notified to CQC.” from the report
Repeated breach
seriousThe home had been in breach of the same reporting requirement at the previous inspection. Inspectors found that enough improvement had still not been made.
“Not enough improvement had been made at this inspection, so the provider remains in breach of regulation 18.” from the report
- 01How will you make sure every serious injury is reported to the CQC and the local authority within the required timescale?
- 02What changes have been made since the inspection to prevent another failure to report serious injuries?
- 03How do you check that incident records, investigations and required notifications all match?
- 04What infection control and visiting arrangements are currently in place, and have they changed since this inspection?
- 05When will the action plan from this inspection be completed, and how will families be told about progress?
This was a targeted inspection of the reporting breach under Well-led and infection prevention and control under Safe; the other areas and ratings were not assessed, and the previous overall Requires Improvement rating carried over. This explanation was written from the published report of 11 November 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 Merlin Court Care Home
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- November 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- July 2019Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2014
Registered with the Care Quality Commission on 13 November 2014.
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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