CQC report explained · a nursing home
What the CQC found at Moundsley House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2022
Rated Good; inspectors found people were safe and well supported, but some environmental repairs and care-plan details needed improvement.
This was an unannounced, focused inspection on 29 March 2022. Inspectors looked at Safe, Effective and Well-led after concerns about staffing, training and medicines. They spoke with nine people, four relatives and nine staff, and reviewed care, medicines, staff and management records.
The home was rated Good for Safe, Effective and Well-led. Inspectors found that risks were managed, medicines were administered safely, infection control was effective, staff were trained, and people were supported to make choices. People and relatives were positive about the managers and staff.
Inspectors did find some environmental problems, including damaged flooring, a broken toilet flush, a wobbly tap and storage issues. These were being addressed. Care plans were reviewed regularly but did not always explain in enough detail how support should be provided.
Managing risks
Staff kept people's risk assessments accurate and up to date. Relatives said managers acted proactively when they were concerned.
“People's safety and ongoing risk was managed well.” from the report
Safe medicines
Medicines were stored securely, records were complete, and staff received training and competency checks.
“Medicine administration records were fully completed and up to date.” from the report
Staff training
Staff had training linked to the needs of people living at the home, including diabetes support, pressure ulcers and moving and handling.
“All staff had received training which was specific to the needs of the people they cared for.” from the report
Choice and consent
Staff asked for consent before providing support and understood the legal safeguards for people who could not make particular decisions.
“Staff confirmed they completed MCA and DoLS training and understood how this was used to support people.” from the report
Positive leadership
People, relatives and staff described the managers as approachable, supportive and easy to contact.
“People and their relatives were positive about the culture of the home.” from the report
Environmental repairs
needs fixingInspectors found several environmental issues, including damaged flooring, a wobbly tap, a broken toilet flush and storage problems. The managers had removed some hazards and provided an action plan for the remaining work.
“Some areas of the home required repairs and renewal work.” from the report
Care-plan detail
needs fixingCare plans were reviewed and personalised, but they did not always explain clearly how staff should provide the required support. This could make it harder for new or agency staff to follow the person's care consistently.
“Care plans stated how many staff would be needed for support but not how that support should be given.” from the report
Quality checks
needs fixingThe management team had not always carried out regular checks to make sure environmental standards were maintained. Vacancies in the maintenance team had delayed some identified work.
“The management team had oversight of the environmental issues identified during the inspection but had not always carried out regular checks to ensure standards were maintained.” from the report
- 01Have all the damaged flooring, broken toilet flushes, wobbly taps and storage issues identified by inspectors now been repaired?
- 02How do you check regularly that environmental safety standards are maintained?
- 03How do care plans explain exactly how my relative's support should be provided, rather than only stating how many staff are needed?
- 04How do you make sure agency and newly appointed staff understand the detailed care each person needs?
- 05What are the current ratings and most recent findings for Caring and Responsive, which were not checked in this inspection?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were used to calculate the overall rating. This explanation was written from the published report of 27 April 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, February 2022
Inspected but not rated; inspectors were assured that infection control and COVID-19 safety measures were being followed.
This was a targeted inspection on 27 January 2022. It looked mainly at infection prevention and control during the COVID-19 pandemic, and asked about staffing pressures. The visit was announced 24 hours in advance.
Inspectors were assured that the home was using protective equipment safely, supporting testing, managing visitors and admissions, and keeping its infection control policy up to date. The home had plans for outbreaks and for reducing the risk of infection spreading.
The home had recently restricted visits during a COVID-19 outbreak, except for people receiving end-of-life care. This restriction had ended by the inspection, and visits had returned to national guidance. The service was inspected but not rated, so this report does not give a full quality rating.
Infection control
Inspectors were assured that the home was preventing infections and following current COVID-19 guidance.
“We were assured that the provider was meeting shielding and social distancing rules.” from the report
Protective equipment
Staff had access to protective equipment in all areas of the home, and inspectors were assured it was being used safely.
“Staff had good access to personal protective equipment such as masks and aprons which were accessible in all areas of the home.” from the report
Outbreak planning
The home had contingency plans for a COVID-19 outbreak and arrangements to reduce cross-contamination.
“The provider had contingency plans in place for if there was an outbreak of COVID-19 and the home and staff had plans in place to reduce the risk of cross contamination.” from the report
Monitoring
The managers kept oversight of vaccination status, isolation periods and COVID-19 test results for people and staff.
“The registered managers both had good oversight of people's and staff vaccination status, isolation periods and COVID-19 test results.” from the report
Recent visiting restrictions
needs fixingVisits had been restricted during a recent COVID-19 outbreak, apart from end-of-life care visits. This had been lifted by the time of inspection, but the restriction had affected contact with relatives.
“The home had restricted visiting for people except those receiving end of life care during a recent outbreak of COVID-19.” from the report
- 01How would you manage visiting if there was another COVID-19 outbreak?
- 02How would relatives keep in contact with residents if visits were restricted?
- 03What measures are currently in place to manage staffing pressures caused by illness or isolation?
- 04How do you check that staff and visiting professionals meet current vaccination or exemption requirements?
- 05When was the home's last full inspection and what were its ratings for the other four questions?
This was a targeted inspection of infection prevention and control and COVID-19-related staffing pressures; the service was inspected but not rated and the other questions were not assessed. This explanation was written from the published report of 11 February 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 Moundsley House
4 rated inspections over 6 years: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- February 2022Inspected but not ratedSafe: Inspected but not rated
- November 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- May 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Registered with the Care Quality Commission on 21 June 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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At least 100 live-in carers within about an hour of Worcestershire
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.
Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.