22 December 2023
During an inspection looking at part of 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.