CQC report explained · a nursing home
What the CQC found at Poets Mews Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people's risks were assessed and managed, medicines were given as prescribed and infection control arrangements were effective. They noted that fridge temperatures in one clinic room had not always been recorded.
- Effective?
- Good
- Staff had training and support, worked with health professionals and helped people with food, drink and healthcare. Relatives gave mixed feedback about personal care and food, which managers said they were addressing.
- Caring?
- Good
- Staff were observed treating people with kindness, dignity and respect. Care records described people's preferences and staff supported people to make choices.
- Responsive?
- Good
- Care plans described people's needs and preferences, and activities were available. Relatives gave mixed views about whether activities suited everyone and whether complaints led to change.
- Well-led?
- Good
- Managers had quality checks and a detailed improvement plan. There was no registered manager at the time, but the area manager and two acting managers were overseeing the home while a new manager took up the post.
What inspectors found, December 2021
Rated Good; inspectors found kind, safe care, but staffing had been under pressure and a new manager was not yet fully in post.
This was an unannounced comprehensive inspection on 20 October 2021. Inspectors spoke with people living at the home, relatives and staff. They reviewed care plans, staff files, medicines records, complaints, incidents and quality checks.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff at the time of the visit, safe medicines systems, assessed risks, kind staff and care that generally met people's needs.
There had been staff turnover and recruitment difficulties. Some relatives felt staffing was too low, although the provider had used regular agency staff, moved staff from other homes and created a recruitment plan. The home also had acting managers and an area manager while a newly recruited manager took up the post.
Safe medicines support
Medicines records showed people received medicines as prescribed. The electronic system and regular audits provided extra checks.
“Medicines administration records (MAR) were accurate and showed people received their medicines as prescribed.” from the report
Action on staffing
The provider recognised the staffing pressures and used regular agency staff and temporary transfers to help meet people's needs while recruiting.
“An in-depth action plan was being followed to ensure that there were enough staff to support people.” from the report
Activities and relationships
People were supported to maintain relationships and join activities. Inspectors found a full programme with social, physical and emotional activities.
“People were supported to maintain relationships and to take part in activities they enjoyed.” from the report
Quality improvement
The management team had identified shortcomings and was following a detailed plan to improve quality and safety.
“Quality checking systems were in place that were getting results to drive up quality and safety.” from the report
Staffing pressure
needs fixingAlthough inspectors found enough staff at the visit, some relatives said staffing was not consistently sufficient. Recruitment and retention were still ongoing.
“Some relatives told us there were not enough staff to consistently meet all their family member's needs.” from the report
Management transition
needs fixingThere was no registered manager at the time of inspection. The area manager and acting managers were running the home until the newly recruited manager was fully in post.
“The service did not currently have a manager registered with the Care Quality Commission.” from the report
Incomplete fridge records
minorThe temperature of one medicines fridge had not always been recorded. This was raised with managers during the inspection.
“The recording of fridge temperatures in one clinic room had not consistently been documented.” from the report
- 01How many permanent and agency staff now work here, and are staffing levels different during the night?
- 02Is the newly recruited manager now fully in post and registered with the CQC?
- 03What changes have been made to improve personal care for people who need more support?
- 04How do you check that food is delivered on time and remains good quality?
- 05How are complaints tracked to make sure repeated concerns lead to changes?
This was the first comprehensive inspection since the service was registered in September 2019, covering all five areas and infection prevention and control; focused inspections in July 2020 and November 2021 had previously looked at Safe and Well-led. This explanation was written from the published report of 8 December 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, December 2020
Inspected but not rated; inspectors found staffing, training and infection control were satisfactory, but this was not a full inspection.
This was a targeted inspection on 26 November 2020. Inspectors looked at staffing levels, staff training and infection prevention and control. They reviewed records, rotas and training information, and spoke with three people and three staff.
Inspectors found enough staff to keep people safe. The manager used a dependency tool to plan staffing and checked call bell response times. Staff said more staff would sometimes help them give people more individual support during pandemic visiting restrictions, but they did not report significant safety risks.
Staff training covered topics relevant to people's needs. New staff said their induction and support were good. Inspectors also found no concerns with infection control and were assured about PPE, testing, admissions, hygiene and outbreak management.
The home was inspected but not rated. It had not yet had a comprehensive inspection, so this report does not give an overall quality rating or full ratings for the five key questions.
Staffing for safety
Inspectors found enough staff to meet people's needs safely. The manager used a dependency tool and said the home was staffing above the number it indicated.
“There were sufficient numbers of staff to ensure people were safe.” from the report
Positive views of staff
People inspectors spoke with were positive about the staff, and this matched what inspectors observed in the home.
“I've no complaints at all about the staff” from the report
Relevant staff training
Training covered areas such as safeguarding, moving and assisting, mental capacity, first aid and pressure ulcer prevention. New staff were able to shadow experienced colleagues before working alone.
“Staff received training in a broad range of topics relevant to the needs of people in the home.” from the report
Infection control
Inspectors found the home was using infection control measures effectively, including PPE, testing, social distancing and arrangements for preventing or managing outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
More individual support
minorSome staff said more staff would sometimes be useful so they could give more individual support to people who could not see family and friends during pandemic restrictions. Staff did not report significant safety risks from staffing levels.
“This was particularly because they felt they wanted to do more for people during the pandemic whilst visiting restrictions were in place.” from the report
Mixed support from a senior carer
needs fixingStaff feedback about the support from the senior carer on their unit was mixed. Inspectors told the manager, who said the issue was being addressed.
“Feedback from care staff was mixed about the quality of support from the senior carer on their unit.” from the report
- 01How do you decide staffing levels when people's needs change or the home is especially busy?
- 02What has changed in response to staff saying they needed more time to give individual support during visiting restrictions?
- 03What action has been taken about the mixed feedback on support from the senior carer?
- 04How do you monitor call bell waiting times, and what happens when demand is high?
- 05When will the home receive its comprehensive inspection and full ratings?
This was a targeted inspection of staffing, staff training and infection prevention and control; it was not a comprehensive inspection and did not assess all five key questions. This explanation was written from the published report of 19 December 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 Poets Mews Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- December 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not rated
- August 2020Inspected but not ratedSafe: Inspected but not rated
- September 2019
Registered with the Care Quality Commission on 4 September 2019.
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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23 live-in carers within about an hour of North Somerset
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 £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
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.