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
- There were enough staff, medicines were administered by trained staff, and risks were generally assessed and recorded. Inspectors found some safety issues, including an open front door on a main road and areas needing repair.
- Effective?
- Good
- People had access to health professionals, food and drink suited to their needs, and support based on mental capacity law. Some staff training was incomplete and formal evidence of staff development was limited.
- Caring?
- Good
- Staff knew people well, respected their privacy and dignity, and supported everyday choice and independence. People were helped to communicate in ways that worked for them.
- Responsive?
- Good
- People’s needs, goals and interests were reviewed, and they were supported to take part in activities and keep family and community links. One newer person’s care plan did not give staff enough guidance about needs and risks.
- Well-led?
- Requires improvement
- People and staff were happy with the support and leadership, but monitoring systems did not always identify problems or show that action was taken promptly. Records, training, supervision, repairs and wider feedback systems needed improvement.
What inspectors found, July 2018
Rated Good overall; inspectors found safe, kind and responsive care, but the home’s leadership and checks needed improvement.
This was an unannounced inspection on 21 May 2018. One inspector and one expert by experience observed care, spoke with seven people, three relatives and three care staff, and reviewed care plans, staff files and safety audits.
Overall, people appeared happy and settled. Staff knew people well, supported their independence and helped them take part in activities, education, work and community life. Medicines, staffing, safeguarding and health support were found to be good.
The main weakness was how the home was managed and monitored. Some training and staff supervision were overdue. Records and care plans were not always complete, and audits had not always led to prompt action on repairs, food safety and other risks.
The overall rating improved from Requires Improvement at the previous comprehensive inspection in October 2016 to Good. Safe and Responsive also improved to Good, while Well-led fell from Good to Requires Improvement.
Enough staff
Staffing was based on people’s assessed needs and activities. The use of regular staff supported continuity of care.
“There were enough staff to meet people's individualised needs.” from the report
Safe medicines
Medicines were given by trained and assessed staff. Records, stock checks and audits were in place.
“There were safe systems for the administration of medicines.” from the report
Active lives
People took part in day services, college, volunteering, shopping, trips and hobbies. Their goals and interests were included in care planning.
“People were supported to stay active and pursue their interests.” from the report
Open front door
seriousThe front door was left open all day. Inspectors said this could allow someone who was vulnerable around traffic and other people to leave when it was unsafe.
“The open door could pose a risk of a person leaving the service when it would have been unsafe for them to do so.” from the report
Incomplete care plan
needs fixingThe care plan for a newer resident did not clearly explain how staff should manage the person’s needs and risks. Staff understood the person, but the written guidance was not sufficient.
“There was no real guidance for staff other than their initial assessment, which highlighted a lot of needs and risks associated with this persons care and support.” from the report
Weak monitoring
seriousAudits had identified some concerns but had not always resulted in timely action. Inspectors could not see what immediate steps had been taken after shower temperatures exceeded recommended levels.
“We could not see what action they had taken to reduce the risk of scalding to people using the service.” from the report
Overdue staff support
needs fixingSome refresher training was overdue, and staff were not receiving the required number of formal supervisions or annual appraisals. The manager said a new supervision planner had been introduced after the visit.
“Staff were not receiving an annual appraisal of their performance or having the number of required supervisions of practice as stipulated in the company's supervision policy of six a year.” from the report
Repairs and cleanliness
needs fixingSome refurbishment was overdue. Inspectors found problems in a bathroom, including inadequate sanitation, and noted an ongoing wet-room leak.
“We found in one of the bathrooms due for refurbishment, the floor was stained, the extractor fan dirty and there was inadequate sanitation.” from the report
- 01How are care plans and risk assessments checked for new or temporary residents, and when was the most recent review?
- 02What arrangements are now in place to make sure the front door is secure while still supporting people’s independence?
- 03What immediate action is taken when shower temperatures or other environmental checks show a safety risk?
- 04Have all staff completed overdue refresher training, regular supervision and annual appraisals?
- 05Has respite care stopped, or are respite places still available?
This was an unannounced comprehensive inspection covering all five CQC questions and reviewing care plans, staff records, observations, discussions and safety audits. This explanation was written from the published report of 18 July 2018 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, November 2016
The Mallards was rated Requires Improvement; inspectors found kind, effective care but gaps in risk assessments and out-of-date care records.
This was an unannounced inspection on 18 October 2016. One inspector spoke with five people living at the home, the manager and three care staff. The inspector also checked two care records and records about training, audits and meetings.
People were generally treated kindly and with respect. Staff supported people with personal care, medicines, activities, cooking and daily tasks. There were enough staff during the visit, medicines were given as prescribed, and people were supported with food, drink and healthcare.
The main weaknesses were in written records. Some risks, including risks linked to going out and bedrails, had not been formally assessed. Two care plans had not been reviewed for over 12 months and no longer fully described people's needs.
The overall rating Requires Improvement means the home was not consistently meeting the standard expected. The questions about Safe and Responsive were also rated Requires Improvement, while Effective, Caring and Well-led were rated Good.
Kind and respectful care
People were supported in a cheerful and patient way. Staff respected privacy, dignity, choices and independence.
“People's privacy and dignity was respected by staff. People's care was provided with kindness and patience and in a way which people preferred.” from the report
Medicines and staffing
Medicines were stored and given safely, with accurate administration records. Inspectors also found enough staff to meet people's needs during the visit.
“Medicines were stored, administered and disposed of in a safe manner and accurate records of medicines administered were maintained.” from the report
Activities and community life
People had regular activities and trips, including day services, shopping, local events and visits with friends and family.
“Activities and day trips took place on a regular basis and photographs of people undertaking different activities were available within the home.” from the report
Staff support and training
Staff had training, supervision and opportunities to discuss their work. They understood people's needs and how to support them.
“Staff received a mixture of e-learning and face to face training to equip them with the skills needed to carry out their roles effectively.” from the report
Risk records were incomplete
seriousRisks linked to community access and bedrails had not been formally assessed and recorded. Important information was also kept separately rather than clearly linked to care plans.
“Risk assessments had not all been formally recorded.” from the report
Care plans were out of date
seriousTwo care plans had not been reviewed for more than a year. One person's needs had changed significantly, but the written plan still said the person could mobilise independently.
“People's care records were not up to date and did not always provide staff with sufficient guidance to provide consistent, individualised care to each person.” from the report
Some medicine guidance needed review
needs fixingGuidance for medicines given when needed had not been reviewed for over a year, so it might not have reflected current needs.
“Although we found that these protocols had not been reviewed for over a year to ensure that they were still appropriate and up-to-date.” from the report
CQC notification was late
needs fixingThe manager had not yet notified CQC about one person's recently authorised deprivation of liberty safeguard.
“The registered manager had yet to complete a notification to inform CQC of this event.” from the report
- 01How have you updated the care plans for people whose needs have changed since this inspection?
- 02How are risks such as going out alone and using bedrails now assessed, recorded and linked to care plans?
- 03How often are 'as required' medicines protocols reviewed, and when were they last checked?
- 04How do you make sure staff can quickly find the current guidance for each person?
- 05What progress has been made on the action plan for care planning and risk assessments?
This was an unannounced inspection of the overall service, covering all five CQC questions; the inspector spoke with five people and reviewed two care records. This explanation was written from the published report of 29 November 2016 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
2 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- July 2018Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 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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