We carried out a review of the data available to us about Mavern House Nursing Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Mavern House Nursing Home, you can give feedback on this service.
We found the following examples of good practice.
The service was proactive in supporting people to maintain contact with friends and family, either through visits, or through the use of telephone and video calls and social media.
The service had provided staff with badges to reassure people that although staff were wearing masks, they still cared for the people they were supporting.
The service had promoted the essential care giver role.
The provider ensured staff had access to well-being support.
The service had introduced measures to prevent visitors from catching and spreading infections. Visitors were screened for COVID-19 and were provided with personal protective equipment (PPE).
Staff had received training on infection prevention and control measures and how to use PPE safely. PPE was available to staff throughout the service and staff were seen using it effectively. Staff competence and knowledge was regularly assessed.
Additional cleaning measures had been introduced in the home. All areas of the home were clean.
COVID-19 testing was being carried out for people using the service and staff in line with the latest guidance.
Mavern House is a Nursing home providing personal and nursing care to 47 people, aged 65 and over, at the time of the inspection. Care was provided in one adapted building across two floors. One area of the building specialised in providing care for people living with dementia. The service can support up to 50 people.
People’s experience of using this service and what we found
There were systems in place to identify and protect people from abuse. Staff were knowledgeable about identifying and reporting signs of abuse. Medicines were managed safely. Personal and environmental risks were assessed and mitigated as much as possible. People were cared for by staff who had been recruited safely and received ongoing training relevant to their role.
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 were supported to maintain good nutrition and hydration. People’s rooms were personalised, and the building was adapted to meet people's needs. The service worked effectively with other health and social care professionals.
People were treated kindly and with respect. People told us staff were caring and knew them well. People were supported to express their views and choices about their care and were supported to be as independent as possible.
Care was personalised to individuals and staff knew people they cared for well. People had detailed end of life care plans in place and staff told us they felt supported to deliver effective end of life care.
The service was well led, the management team were supportive of staff and modelled person-centred values. The registered manager was knowledgeable about their regulatory responsibilities and kept up to date with best practice guidance.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 3 July 2019) and there was one breach of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People’s experience of using this service:
People were not always supported by sufficient numbers of staff. This impacted on the amount of time they waited for assistance and support. Analysis of call bell data was not effective in making improvements to the time people had to sometimes wait for assistance.
Whilst people enjoyed the food at the service, there was not always enough staff for them to have the support they needed at mealtimes. People were sat watching other people eat whilst they waited for help and support.
We have made one recommendation about supporting people to eat at mealtimes.
People were sometimes spoken about in an undignified way. Some interactions we observed compromised people’s dignity. However, all the feedback from people about the staff was positive. People told us staff were kind and caring.
People were supported by staff who had been recruited safely and had the skills needed to provide effective care. Staff received support and training from the organisation and enjoyed working at the service.
Risks had been identified and assessed. Risk assessments were reviewed regularly. People had individual care plans which provided guidance for staff to follow. The provider was transferring to an electronic system of care planning which they said would improve their current care plan system.
People received their medicines as prescribed and medicines were managed safely. People could see healthcare professionals when needed and supported to live healthy lives.
People were able to follow their interests and access the local community if they wanted to. Staff did not record activities consistently, this meant for some people there was not an accurate record of what they had done during the day.
Complaints were recorded and investigated. People, relatives and staff told us the service was well-led.
The registered manager was a visible presence and knew people and their relatives well. People’s feedback was encouraged and used to make improvements.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.
Rating at last inspection: At our last inspection in October 2016 (published December 2016) we rated this service as good overall. We rated Safe, Effective, Caring and Well-led as good and the key question Responsive requiring improvement.
Why we inspected: This was a planned comprehensive inspection based on the rating at the last inspection.
Enforcement: We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for staffing. Details of action we have asked the provider to take can be found at the end of this report.
Follow up: We will continue to monitor intelligence we receive about the service until we return as per our inspection schedules. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
The inspection took place on 25 and 26 October 2016 and was unannounced.
On the day of our inspection, there were 48 people living at the home. There were two lounges, an activities room, a separate dining room, bathrooms and toilets and a passenger lift to give easier access to both floors.
A registered manager was employed by the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was present on both days of the inspection.
The ordering, storage and disposal of medicines was managed effectively. We observed a medicines round during the inspection. The administration of medicines was done in accordance with current guidelines and regulations. However, there were gaps in signing of administration of some medicines which had not been identified by staff.
People told us they felt safe when receiving care. Staff were able to tell us how to recognise signs of potential abuse and what action to take if they had any concerns. People’s risk assessments had been made and recorded in people’s care files.
There were sufficient numbers of suitable staff to support people and safe recruitment practices had been followed before new staff members started working at the home. Staff responded to people’s needs in a calm and proficient way and had sufficient knowledge to provide support and keep people safe.
Arrangements were in place for keeping the home clean and help reduce the risk and spread of infection. People’s rooms and sanitary ware in bath and shower rooms were kept clean. Staff had sufficient personal protective equipment available which we saw being used throughout the inspection.
The service had a clear understanding on the requirements of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). Following a recent audit which had looked at people’s care plans, the need to implement improved documentation; particularly around consent had been identified and the new processes were now in place. Some care records had been updated in response to this and the service were in the process of completing this for all people using the service.
Staff received regular training in relation to their role and the people they supported and told us this had supported them to do their job effectively. Staff received regular supervisions and an annual appraisal where they could discuss personal development plans. This meant staff received the appropriate support to enable them to provide care to people who used the service.
People were supported to maintain good health and had access to health services which included regularly seeing their GP with additional visits according to any changing healthcare requirements. We saw an example of this during the inspection when one person who had become unwell had been referred to their GP.
People and their relatives were positive about the care and support they received from staff. We saw staff support people in a kind and friendly way which also protected their privacy and dignity.
The documentation to monitor diet and fluid intake of people who were at risk of malnutrition and/or dehydration were not consistently completed. However, records to monitor risks identified in other areas such as pressure care were well recorded and this information had been well communicated between staff for example, during staff handover.
Staff understood the needs of people they were providing care for. Care plans were individualised and contained information on people’s preferred routines, likes, dislikes and medical histories.
People, their relatives and staff were encouraged to share their views on the quality of the service. They told us management were approachable and they were confident if they had any concerns they would be taken seriously and addressed accordingly.
Staff spoke highly of how the service was managed and as well as there being an open door policy, regular staff meetings took place to allow staff to voice their feedback and be updated on best practice.
There were systems in place to monitor and improve the quality and safety of the service provided. Where actions to improve the service had been identified, these had been acted upon.
People's health and welfare needs were being met and the support they received was appropriate to their needs. People and their relatives were very happy about the care provided. We found the management of medications to be safe and appropriate to people's needs.
We found that people were supported by well trained staff who in turn, were well supported by the home's management team. The quality of the service was being monitored and systems were in place to meet people's health, welfare and safety needs.
People said they appreciated having their own rooms, and being able to choose how they were decorated. One person told us "I have brought some of my own things into the home'.
Staff responded quickly to people when they asked for assistance. People told us
their rights to privacy and dignity were promoted.
Staff members made sure when they spoke to people who used wheelchairs they were at their eye level. People were invited to join in conversations about current affairs and people were spoken to respectfully.
People told us they would tell a member of staff or the manager if they were unhappy with their care or treatment. They said staff listened and they were confident that any issue would be satisfactorily resolved.
We saw on people's care files that the views of relatives, social workers and health professionals were sought in the provision of care. We saw that people completed
questionnaires about the service and there were many positive comments.
People look well presented. People in bed looked comfortable with clean nightwear and fresh bedding. Call bells were within easy reach and people said they knew how to use them. Staff responded quickly to people when they asked for assistance. People told us their rights to privacy and dignity were promoted although we noted a number of areas which compromised this.
There were many social activities within the home that people could join in with. In addition, there was a resident artist, a resident story teller, a reflexologist and a community choir. People said there were regular trips out and about within the local community. There is a sensory garden for people to enjoy.