CQC report explained · a nursing home
What the CQC found at Mr 'C's
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, staffing, risk assessments and infection controls had improved, although inspectors found some incorrect mask use, missing building fixtures and missed signatures on cream records.
- Effective?
- Good
- This question was not inspected during this visit. Its rating was carried over from the previous inspection for the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its rating was carried over from the previous inspection for the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating was carried over from the previous inspection for the overall rating.
- Well-led?
- Good
- Managers had improved audits, monitored incidents and acted on the previous action plan. Some staff nevertheless reported that they lacked formal one-to-one meetings or supervision.
What inspectors found, July 2022
Rated Good; inspectors found safe, caring care and improved management, but noted mask, building and staff supervision shortfalls.
This was an unannounced inspection over three days. Inspectors spoke with people, relatives and staff, reviewed care and medicines records, checked recruitment files, and examined how the home was managed.
The home was rated Good overall. People and relatives said they felt safe and spoke positively about the caring culture. Medicines management, risk assessments, staffing checks and infection control were mostly sound. Some staff were not wearing masks correctly, and missing fixtures in the building were found, but these issues were addressed during the inspection.
The home had improved since the previous inspection, which was rated Requires Improvement and found breaches of regulation. At this inspection, the provider was no longer in breach. However, some staff said they did not receive formal one-to-one supervision, and inspectors recommended improvements to this process.
Improved medicines management
People were receiving their medicines as prescribed. The home had improved the timing of medicine rounds, stock checks and guidance for medicines given when needed.
“Medicine administration records (MAR) had been completed and showed people had received their medicines as prescribed for them.” from the report
People felt safe
People and relatives said they felt safe. Staff knew how to report abuse and understood the risks affecting the people they supported.
“People and their relatives told us they felt safe living at Mr'C's.” from the report
Enough staff
People, relatives and staff said there were enough staff to meet people's needs. Recruitment checks had been completed before staff started work.
“People, relatives and staff told us there were enough staff to meet their needs.” from the report
Better oversight
The home had strengthened its checks and audits. It monitored accidents and incidents and used the findings to make improvements.
“Processes were in place to monitor and analyse accidents and incidents and the analysis was used to identify issues and mitigate the risk.” from the report
Incorrect mask use
needs fixingTwo staff were seen wearing face masks incorrectly. The manager addressed this immediately and said staff would complete refresher infection-control training.
“At the start of the inspection, we observed two staff not wearing their face mask correctly.” from the report
Building fixtures
needs fixingInspectors found missing radiator covers and a window restrictor that had come apart. The manager took immediate action to make the environment safe.
“During a tour of the building we saw radiators were missing covers in two people's en-suite bathrooms and one window restrictor had come apart.” from the report
Incomplete cream records
needs fixingSome topical medicine records did not have staff signatures. The manager said daily oversight would be increased to check these records were completed.
“During the inspection we saw some missing signatures on topical medicine administration records (TMAR) of people's prescribed creams.” from the report
Staff supervision
needs fixingSome staff said they did not have formal one-to-one meetings to discuss their performance or training needs. Inspectors recommended that the provider improve its supervision process.
“Some staff told us they did not have formal one-to-one meetings or supervisions to discuss their performance or training needs.” from the report
- 01How do you now check that staff wear their masks correctly and complete infection-control refresher training?
- 02What checks are in place to make sure radiator covers, window restrictors and other fixtures remain safe?
- 03How do you make sure staff sign topical medicine records every time prescribed creams are applied?
- 04What changes have you made to formal one-to-one supervision since the inspection?
- 05How do your audits check that medicines given when needed have enough person-centred guidance?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 6 July 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 2021
Requires Improvement; inspectors found kind care but medicines were not always managed safely and management checks were not effective enough.
This was an unannounced focused inspection on 27 and 30 November 2020. Inspectors spoke with people, relatives, staff and the manager. They reviewed care records, medicine records, recruitment files and management records.
People said care was effective, caring and responsive. Staff were described as kind. Inspectors found enough staff to meet people's needs and were assured that infection control arrangements were being followed.
However, some medicines were late or unavailable. Records for some medicines were incomplete, and checks did not identify these problems. The service breached Regulation 12 on safe care and treatment.
The overall rating changed from Good to Requires Improvement. Safe remained Requires Improvement, and well-led fell from Good to Requires Improvement. The other areas were not inspected at this visit, so their previous ratings were used.
Kind and responsive care
People and relatives spoke positively about the care. Staff were described as kind and considerate.
“People told us they continued to receive care that was effective, caring and responsive to their needs.” from the report
Enough staff
Inspectors found that staffing levels were enough to meet people's care needs, although staff could be busy when colleagues were off sick.
“There were enough staff to meet people's needs.” from the report
Infection control
Inspectors were assured that the home was using protective equipment, testing and infection control practices appropriately. No Covid-19 outbreak had occurred.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt safe
People and relatives said they felt safe and could raise concerns with staff.
“Everyone we spoke with was happy that they or their family member, was safe.” from the report
Medicines were not always safe
seriousSome time-sensitive medicines were given late, one person's medicine was missed, and some medicines were unavailable for several days. Medicine records and checks were also incomplete.
“Not ensuring the safe management of medicines is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak quality checks
needs fixingThe home's audits had not found or fixed the medicine problems. Inspectors also found that action plans did not always show whether other shortfalls had been dealt with.
“Systems of governance were not sufficiently robust.” from the report
Recruitment records
needs fixingSome staff had started using checks from previous employers while new checks were pending. Shadowing during this period had not been recorded, and one check did not cover work with adults.
“We recommend the provider ensures their recruitment process is in line with current guidance and safer recruitment practices.” from the report
Staff changing area
minorThe staff changing area was very small and close to the kitchen. Inspectors recommended reviewing it to reduce the risk of cross-contamination.
“We recommend the provider reviews the area where staff change to maximise the ability to prevent cross contamination.” from the report
- 01What has changed since the inspection to make sure time-sensitive medicines are given on time?
- 02How do you now check that medicines are in stock and that prescribed creams are recorded correctly?
- 03What evidence can you show that medicine audits now identify and fix problems?
- 04How do you check that new staff have the correct background checks before they work with residents?
- 05What changes have been made to the staff changing area to reduce cross-contamination?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used. This explanation was written from the published report of 13 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.
Every inspection of Mr 'C's
6 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019Goodup from Requires improvementSafe: Requires improvementWell-led: Good
- February 2018Requires improvementup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- October 2013
Registered with the Care Quality Commission on 11 October 2013.
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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21 live-in carers within about an hour of Torbay
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 £1,400 a week. 17 can care for a couple. 12 years' experience on average.
“She looked after my mum, who can be incredibly challenging, so well and so gently, and we always felt confident that my mum was getting the best care available.”
“She was not phased by anything, she was adaptable, kind & gave us complete confidence to go away & not worry about a thing!”
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.