CQC report explained · a nursing home
What the CQC found at Mother Red Caps Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People were protected from abuse and medicines were administered safely. However, parts of the building needed repair, some cleaning checks had missed problems, and some people said staff could be slow to respond when busy.
- Effective?
- Requires improvement
- This area was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This area was not inspected as a separate key question during this focused visit. Inspectors did observe caring and supportive interactions, although staff practice differed between units.
- Responsive?
- Good
- This area was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- The manager was approachable and acted on feedback, but quality checks had not identified many maintenance and cleanliness problems. The provider was in breach of Regulation 17 because governance systems were not effective enough.
What inspectors found, January 2024
Rated Requires Improvement; inspectors found people were generally safe and cared for, but repairs, cleaning checks and governance were not reliable.
This was an unannounced focused inspection on 14 and 22 December 2023. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home had enough staff according to senior staff, but it regularly used agency staff while recruiting permanent workers. People were protected from abuse, medicines were managed safely, and risk assessments and care records gave staff useful guidance.
Inspectors found many repairs and cleaning issues, including damaged surfaces, broken radiators and a loose shower screen. The manager acted quickly on several issues during the inspection, but checks had not found most of them and there was no confirmed timetable for the wider refurbishment.
The overall rating remains Requires Improvement. Safe and well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were carried forward. The home has held this overall rating for four consecutive inspections.
Safe medicines
The home had safe medicine procedures. Staff received updated training and medicine audits had improved.
“The provider had safe processes in place to support people with prescribed medicines.” from the report
Action during inspection
The manager responded quickly to risks found during the inspection, including repairs to some radiators and other hazards.
“By day two of the inspection the registered manager had taken responsive action to ensure repairs carried out to potential risks and radiators in bedrooms had been repaired.” from the report
Care records and risk plans
Care records were individualised. Risk assessments and care plans gave staff guidance to reduce avoidable harm.
“Risk assessments outlined measures to help reduce the likelihood of people being harmed, and care plans contained guidance for staff about how to keep people safe.” from the report
Positive relationships
People and relatives spoke positively about staff and management. Inspectors also saw caring interactions.
“We observed caring and supportive interactions between people living at the service and staff.” from the report
Building repairs and hazards
seriousInspectors found damaged walls and woodwork, broken radiators, a loose shower screen and other repair issues. Some of these could create risks for people using the home.
“some walls had sharp broken edges that posed a risk to people walking past, some radiators did not work and had no heat despite being on the highest setting” from the report
Weak management checks
seriousAudits had not identified most of the maintenance and cleaning problems found. The provider was in breach of Regulation 17 for failing to operate effective governance systems.
“The provider had failed to take reasonable steps to ensure good governance of the service.” from the report
No refurbishment timetable
needs fixingThe provider recognised that the building needed full refurbishment, but had not given people and relatives confirmed dates for the work to start and finish.
“the management team had no confirmed plans to show to people and relatives when work would start and be completed to improve all parts of the service.” from the report
Use of agency staff
needs fixingThe home regularly used agency staff while recruiting permanent workers. Some people and relatives said there seemed to be too few staff at busy times and that call bells could take a while to be answered.
“They could do with more staff and they get agency in, although they try and get the same ones, sometimes when they're busy it takes a while for them to come if I ring the buzzer” from the report
- 01Which repairs identified by the inspectors have now been completed, including the sharp wall edges, radiators, shower screen and kitchen fire door?
- 02What is the confirmed timetable for the wider internal and external refurbishment, and how will relatives be updated?
- 03How are you checking that cleaning and maintenance problems are found promptly rather than missed by audits?
- 04How many permanent staff have been recruited, and how will you reduce reliance on agency staff, particularly at weekends?
- 05How will you make sure staff respond promptly to call bells when the home is busy?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried forward from the previous inspection. This explanation was written from the published report of 17 January 2024 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, September 2022
Rated Requires Improvement; inspectors found safe care was not always reliable and identified problems with infection control, records and leadership.
The unannounced inspection took place on 14 July 2022. Inspectors reviewed care, medicine and staff records, spoke with relatives and staff, and checked the home and its management systems.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe and Well-led. Inspectors found problems with COVID-19 testing, some safety checks, care records and regular meetings with relatives. The home used many agency staff because of recruitment difficulties.
There were also positive findings. Staff understood safeguarding procedures, medicines were given as prescribed, risk assessments were in place, and people were supported with their legal rights and healthcare needs. The provider took some action after the inspection, but the CQC said it would continue to monitor the home.
Safeguarding
Staff knew how to report suspected abuse and whistleblowing concerns. Safeguarding incidents were reported appropriately.
“Staff understood what to do if they had safeguarding concerns.” from the report
Medicines
Inspectors found that medicines were ordered, given, recorded and stored safely. Records showed people received their medicines as prescribed.
“Medicine administration records (MARs) showed people had received their medicines as prescribed.” from the report
Risk planning
Care plans and risk assessments included guidance for staff on reducing avoidable harm. Emergency evacuation plans were in place.
“Risk assessments outlined measures to help reduce the likelihood of people being harmed, and care plans contained guidance for staff about how to keep people safe.” from the report
Supportive relationships
Inspectors observed caring interactions. Relatives and staff described managers as supportive and approachable.
“We observed caring and supportive interactions between people living at the service and staff.” from the report
Healthcare support
The home worked with health professionals and other agencies to support people's specialist healthcare needs.
“The provided worked in partnership with other agencies and health professionals to improve outcomes for people and ensure they received specialist healthcare when they needed it.” from the report
COVID-19 testing
seriousStaff COVID-19 lateral flow testing was not always completed twice a week in line with government guidance. The provider put a recording system in place after the inspection.
“Records showed that rapid lateral flow tests (LFT) for COVID-19 were not completed twice weekly by all staff.” from the report
Safety checks
seriousSome beds did not have their brakes fully engaged. Inspectors also found a wet floor and doors that did not fully close.
“We identified several beds that did not have their brakes fully engaged putting people at risk.” from the report
Care records
needs fixingSome daily records were missing entries, and inspectors found inconsistencies in repositioning and personal care monitoring. Some important information was also missing from care records.
“People's support needs were not always monitored accurately.” from the report
Use of agency staff
needs fixingStaffing numbers were appropriate, but the home relied heavily on agency staff because of recruitment difficulties. Staff said this affected morale.
“There was a high volume of agency staff being utilised to maintain these levels.” from the report
Family involvement
needs fixingResident and relative meetings did not always take place regularly. The provider said it addressed this after the inspection.
“People and relatives were not always fully engaged in the running of the service.” from the report
Management oversight
needs fixingQuality checks were in place but had not prevented all the infection control problems found by inspectors. There was no registered manager in place at the time of the visit.
“We did however identify IPC issues in relation COVID-19 testing regimes.” from the report
- 01How do you now make sure every staff member completes the required COVID-19 tests and that results are recorded?
- 02How are bed brakes, doors, wet floors and other environmental safety issues checked each day?
- 03What has changed to make sure repositioning, personal care and daily records are complete?
- 04How much agency staff are currently being used, and what is the plan for recruiting permanent staff?
- 05How often are resident and relative meetings now held, and how are families invited to them?
This was a focused inspection prompted by a review of information, covering Safe and Well-led; the other key question ratings were not inspected during this visit. This explanation was written from the published report of 2 September 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.
Every inspection of Mother Red Caps Home
7 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- January 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2021Requires improvementup from InadequateSafe: Requires improvementWell-led: Requires improvement
- December 2020Inadequatedown from GoodSafe: InadequateEffective: Requires improvementWell-led: Inadequate
- June 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- May 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2015
Report published without a new overall rating.
- February 2015
Report published without a new overall rating.
- October 2014
Report published without a new overall rating.
- March 2014
Report published without a new overall rating.
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- May 2012
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 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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