CQC report explained · a residential care home
What the CQC found at The Mallards
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risks were assessed and managed, with enough suitable staff to meet people's needs. Medicines were administered safely and infection control measures were followed.
- Effective?
- Good
- People's needs were assessed before moving in, and staff had suitable training and support. People received help with food, drink, healthcare and healthier living.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. They knew people's preferences and involved them in everyday decisions about their care.
- Responsive?
- Good
- Care plans were personalised and regularly reviewed. People were supported with communication, activities, relationships, complaints and plans for end-of-life care where appropriate.
- Well-led?
- Good
- Inspectors found effective management, communication and quality checks. People, relatives and staff were positive about the leadership, and feedback was used to make improvements.
What inspectors found, September 2023
The Mallards is rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
Inspectors visited without notice on 17 August 2023. They spoke with 8 people, 3 relatives, 9 staff and a visiting health professional. They also checked care records, medicines records, staff recruitment files, training records and management audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough suitable staff, safe medicines systems, good infection control and care plans that reflected people's needs and preferences.
People were described as receiving kind and respectful care. Staff knew people well, supported their choices and helped them take part in activities. The home also supported people's food, drink, healthcare, communication and contact with relatives.
The previous inspection in 2019 rated the home Requires Improvement and found breaches relating to safe care, staffing, person-centred care and governance. This follow-up found enough improvement, and the home was no longer in breach of those regulations.
Kind, personal care
Staff knew people well and provided care that reflected their individual routines, preferences and communication needs.
“People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Activities and relationships
People had regular activities and were supported to keep in touch with family and friends. Activities included arts and crafts, bingo, garden parties and trips out.
“People were supported to take part in a range of activities they enjoyed and were encouraged to explore new activities if they wanted to.” from the report
Good management
The home used audits, feedback and incident reviews to identify improvements. Staff said communication was good and they felt listened to.
“There were systems in place to monitor the quality of the service; actions were taken, and improvements were made when required.” from the report
Food and healthcare
People enjoyed the meals and were offered choices, including food reflecting cultural needs. Staff worked with health professionals when people needed extra support.
“The chef said they visited everyone in the morning and again in the afternoon to seek their choice of meal for that day.” from the report
Previous inspection weaknesses
minorThe previous inspection in 2019 found problems with safe care, staffing, person-centred care and governance. These were described as improved and were not breaches at this inspection, but families may still wish to ask how the improvements are maintained.
“The last rating for this service was Requires Improvement (published 24 September 2019)” from the report
- 01How do you check that staffing levels remain sufficient when people’s needs change or staff are absent?
- 02How are medicines administration records checked, and how quickly are any errors investigated?
- 03How often are care plans and risk assessments reviewed, and how are families involved when needs change?
- 04What activities are currently available, and how do you make sure they reflect each person's interests and culture?
- 05What improvements have been made since the 2019 inspection, and how do you monitor that they continue?
This was an unannounced follow-up inspection that rated all five key questions and also checked infection prevention and control; it followed the previous comprehensive inspection in 2019. This explanation was written from the published report of 2 September 2023 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 2019
Rated Requires Improvement; inspectors found risks from poor hygiene, limited staffing and inconsistent person-centred care.
This was an unannounced inspection on 21 August 2019. Inspectors spoke with people, relatives, staff and managers. They reviewed care records, medicines, staff files, safety checks and other documents.
Inspectors found dirty equipment, unclean bathrooms and other infection control risks. Some risk assessments did not give staff enough guidance. There were also concerns about medicines records, moving people safely and staffing levels. The provider sent an action plan and began some work during and shortly after the inspection.
People did not always have a good dining experience or enough choice about food and drink. Staff did not always support people with dignity, activities or their communication needs. Staff and relatives described the care team and manager as kind and committed, but quality checks had not found the problems.
All five areas were rated Requires Improvement. This was a deterioration from the previous overall rating of Good, published in March 2017. Caring had previously been rated Outstanding.
People felt safe
People who could communicate with inspectors said they felt safe living at the home.
“People told us that they felt safe living at the home.” from the report
Kind staff
People and relatives described staff as kind and caring. Inspectors also saw staff speaking politely and gently to people.
“We observed staff were polite and kind to people.” from the report
Support for weight loss
There was a clear process for responding when people lost weight, including referrals to specialist food teams.
“There was a clear safe process in place to follow. We saw referrals to food specialist teams.” from the report
Staff support
Staff said their induction and training were positive and that the manager supported them.
“Staff spoke positively of the induction and training. They all felt supported by the registered manager.” from the report
Action after concerns
The provider took some action during and soon after the inspection and sent CQC a detailed improvement plan.
“When we raised our concerns with the registered manager, the nominated individual and the owner took certain actions to address some of these concerns.” from the report
Poor hygiene
seriousInspectors found dirty equipment, faecal matter, stained items and other infection control risks. This could have put people at risk of harm.
“There were poor hygiene and infection control practices at the service. This placed people at potential risk of harm.” from the report
Not enough staff time
seriousStaff were too busy with tasks and did not have enough time to talk with people, support activities or meet their social needs.
“There was not enough staff to meet people's social needs.” from the report
Dining support and choice
needs fixingPeople had limited choice about meals. Inspectors saw poor support with eating, and pureed food was not made appealing.
“People did not always have a positive dining experience.” from the report
Dignity during transfers
needs fixingPeople's clothing became loose or rucked up during hoist transfers, and staff did not always correct this. One person appeared distressed.
“We saw four occasions when people's clothing had become loosened or rucked up, with no attempt by staff to promote their dignity.” from the report
Incomplete care guidance
needs fixingSome care plans and risk assessments did not explain clearly enough how staff should respond to people's specific needs, including agitation and depression.
“The assessments lacked details to support staff to meet some of people's specific needs.” from the report
Weak quality checks
seriousThe home's audits had not identified serious problems with cleanliness, maintenance, dining, staffing and people's social experience.
“There was a lack of meaningful audits and checks about people's social experience at the home.” from the report
- 01Which cleaning, repair and infection control actions from the CQC action plan have now been completed?
- 02How many staff are on duty at different times, especially in the evening, and how is this enough time for activities and social contact?
- 03How are creams checked for opening dates and expiry dates, and how are boxed long-term medicines audited?
- 04How do staff now offer meal choices and make sure pureed food is suitable and appealing?
- 05How are care plans, best-interest decisions and end-of-life wishes being reviewed with people and their relatives?
This was an unannounced inspection covering all five CQC questions, including both the care provided and the home's premises. This explanation was written from the published report of 24 September 2019 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 The Mallards
4 rated inspections over 8 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 16 November 2010.
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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