Mother Red Caps Home

Updated 17 January 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was carried out by 1 inspector and 1 regulatory coordinator and 1 Expert by Experience. (An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.)

Service and service type

Mother Red Caps Home is a ‘care home.’ People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

The service did have a registered manager in place.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key what they do well, and improvements they plan to make. This information helps support our inspections. We used this information to plan our inspection.

During the inspection

We spoke with 9 relatives and 5 people living at the home about their experience of the care provided. We spoke with 10 staff that included the registered manager, deputy and area manager.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included three people's care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision and a variety of records relating to the management of the service, including policies and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found during the inspection and the evidence provided after the site visit.

Updated 17 January 2024

About the service

Mother Red Caps Home is a care home providing nursing and personal care for up to 51 people, some of whom are living with dementia. There were 47 people living in the home at the time of the inspection.

People's experience of using this service and what we found

The provider had implemented some refurbishment such as the development of newly refurbished bathrooms. However, we noted a high volume of repairs needed for the environment such as scraped doors, windows, door frames, scraped worn flooring, repairs throughout the building including faults to some radiators. The registered manager was responsive in her actions and by day two of this inspection had taken appropriate actions for auditing and improving cleaning schedules and repairs. The refurbishment and development of the home needs confirmed timescales to improve and enhance the service.

Systems to monitor the quality and safety of the service were in place but needed further review to identify issues raised during the inspection around maintenance, repair and cleaning of the service. The registered manager was open to improvement and listened and acted on feedback and demonstrated a commitment to keep improving the service.

Staffing levels were appropriately managed by senior staff. However due to current difficulties recruiting new staff, the home had regularly used agency staff. Staff showed us they were taking action to recruit more permanent staff and were in the process of arranging inductions.

People were protected from abuse because staff understood the correct procedure to follow if they had any concerns. Staff were knowledgeable and shared lessons learnt from seeking training and sought support from other health professionals as appropriate to support people's needs. People told us they felt safe and their relatives also found the service safe.

Care records were individualised and reflected each person's needs and preferences. Risk assessments had been updated and staff had guidance to help them support people to reduce the risk of avoidable harm. Medicines were administered safely and actions had been taken to train staff and audit improved practices at the service.

People, relatives and staff spoke positively about the management of the service who they felt were approachable and listened to their views.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People had the necessary capacity assessments and legal processes in place to ensure their rights were fully respected.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was rated requires improvement (published 02/09/2022). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvement had been made however, at this inspection, we found that the provider had failed to make sufficient improvements within the service. This meant the service was in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We undertook a focused inspection to review the key questions of safe and well-led only. For those key question not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Mother Red Caps Home on our website at www.cqc.org.uk

Enforcement

We have identified a breach of the regulations in relation to lack of effective governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

Will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.