• Care Home
  • Care home

Archived: Noss Mayo Residential Home

Overall: Requires improvement read more about inspection ratings

2 High Street, Burgh Le Marsh, Skegness, Lincolnshire, PE24 5DY (01754) 810729

Provided and run by:
Mr & Mrs P C Kadchha

All Inspections

15 June 2022

During a routine inspection

About the service

Noss Mayo is a residential care home providing accommodation and personal care to 13 people aged 65 and over at the time of the inspection. The service can support up to 14 people.

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

Quality assurances systems had continued to be developed and implemented. However, we found further work was required as some of these still did not ensure effective oversight of the care home.

Care plans detailed how to support the person to ensure their assessed needs could be met. We found some clear plans required further work to ensure they contained current up to date information to meet people’s needs.

Safe recruitment systems and processes were in place. Training was provided for staff to ensure they could carry out their role safely and effectively, any gaps had been identified and addressed by the registered manager.

People’s nutritional needs were met and detailed in their care plans. Mealtime experiences were positive and people who required a modified diet were well supported.

People told us they felt safe. People and staff provided positive feedback on the management of the service.

Staff had received safeguarding training and were able to demonstrate their understanding and responsibilities to reduce the risk of harm to people.

Staff showed a caring approach to how they supported people. Empathy and compassion were demonstrated for people at the end of their lives.

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.

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 inspection for this service (published 06 January 2022) concerns were raised regarding risk management, medicines management, governance and leadership. We found the provider was in breach of regulation 12 and 17 and a warning notice was issued. This was a focussed inspection and we did not review all key questions. The provider completed an action plan to show what they would do and by when to improve.

The last rating for this service was requires improvement (published 06 January 2022). The service remains rated requires improvement.

Why we inspected

We undertook this inspection to check whether the provider had met the breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014 and that the Warning Notice we previously served had been met. The provider met the warning notice, however, remains in breach of regulation 17. The overall rating for the service has not changed following this comprehensive inspection and remains Requires Improvement.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Noss Mayo Residential Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified a breach in relation to governance at this inspection.

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

Follow up

We 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 alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

18 November 2021

During an inspection looking at part of the service

About the service

Noss Mayo Residential Home is a residential care home providing personal and nursing care to 13 people aged 65 and over at the time of the inspection. The service can support up to 14 people.

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

Since the last inspection the provider had demonstrated improvements within the service. Issues were found with environment, staffing and health and safety. We saw improvement in all these areas with adequate staffing in place to meet people’s needs and measures in place to support good health and safety within the home.

The provider demonstrated a variety of systems to monitor the quality of the service. However, there were shortfalls in organisational governance and new risk was found. For example, pressures care management and controlled drugs procedures.

The systems and processes in place needed time to be embedded and further developed to show the systems were effective and improvements found would be sustained.

Risk Management was not always effective in identifying potential harm to people. Staff did not always demonstrate understanding of safeguarding and risk, meaning we could not be assured timely action was always taken .

Accidents and incidents were not always managed effectively. Systems in place were not used robustly for staff to report incidents. The provider had also failed to analyse and learn from events.

Medicines were managed safely, and people received their prescribed medicines. However, further improvements were needed to ensure the recording of controlled drugs administration was accurate.

There were enough staff to meet the needs of people. Records showed staff had the relevant training in place to support people.

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 inspection for this service (published 02 August 2021) was a targeted inspection to check whether the provider had met the requirements of the Warning Notice in relation to Regulations 12 (safe care and treatment), 17 (good governance) and 18 (staffing). We found the provider had made improvements and the service was no longer in breach of regulations 12 and 18. This was a targeted inspection and we did not review entire key questions; therefore, we did not review the rating at this inspection.

The last rating for this service was inadequate (published 31 July 2021) and there were breaches of regulations 12, 17 and 18. The provider completed an action plan to show what they would do and by when to improve. At this inspection we found some improvements had been made and the provider was no longer in breach of regulation 18 but remained in breach of regulations 12 and 17.

This service has been in Special Measures since December 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Inadequate to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Noss Mayo Residential Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to the registered provider’s assessment and management of potential risks to people’s safety, infection control management and organisational governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

10 March 2021

During an inspection looking at part of the service

About the service

Noss Mayo Residential Home is a residential care home providing personal and nursing care to 11 people aged 65 and over at the time of the inspection. The service can support up to 14 people.

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

Organisational governance and quality assurance arrangements had either not been developed or had not been effective in monitoring and improving the quality and safety of the service.

The provider demonstrated a variety of systems to monitor the quality of the service. However, the processes in place needed time to be embedded and further developed to show the improvements found would be sustained.

Medicines management had been updated giving clear guidance to staff when administering medicines. Further improvements were needed to identify shortfalls when auditing.

Staff received appropriate training in relation to their role, additional specific training was available to staff to meet the needs of people they support.

Staff followed national guidance in relation to wearing personal protective equipment during the COVID-19 outbreak. This practice was monitored by the manager.

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 Inadequate (published 24 December 2020). We found breaches of regulations and the provider was served with Warning Notices. 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 12 and 18 but remained in breach of Regulation 17.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains Inadequate.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

20 October 2020

During an inspection looking at part of the service

About the service

Noss Mayo Residential Home is a residential care home providing personal and nursing care to 12 people aged 65 and over at the time of the inspection. The service can support up to 14 people.

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

There were significant shortfalls in organisational governance. The provider had a quality control policy in place. However, the policy did not describe who was responsible for undertaking audits to ensure regulatory compliance. There was insufficient detail regarding monitoring timeframes and quality assurance processes which increased the risk to people's safety and welfare.

There was a lack of quality assurance processes in place to monitor the quality of the service and address shortfalls. For example, several audits were either not in place or not comprehensive enough to identify all environmental and health and safety issues that the inspectors identified during the site visit.

People did not always receive their prescribed medicines or topical medicines. Alternative methods of administration and contact with healthcare professionals had not taken place, which put people at increased risk of health deterioration.

Staff were consistently not wearing the correct PPE in line with government guidelines. Service users were at increased risk of contracting infection by the provider’s failure to ensure the correct Personal Protective Equipment (PPE) were being worn by all staff.

Some staff had not received some of the training identified as mandatory by the provider.

Notifications about significant events that had happened in the service had not been submitted to CQC, as required in law.

Staff were positive about their experience of working in the service. Most people and their relatives also provided positive feedback on the caring, friendly nature of staff.

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 Good (February 2019)

Why we inspected

We received concerns about a number of issues including the management of people’s care, the safety of staff deployment and infection control measures. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

Enforcement:

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches of regulations in relation to the registered provider’s assessment and management of potential risks to people’s safety, the deployment of staffing and organisational governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

12 February 2019

During a routine inspection

About the service:

Noss Mayo Residential Home provides accommodation, care and support for up to 14 older people who have physical disabilities, some of whom may experience memory loss and have needs associated with conditions such as dementia.

There were 12 people living at the service at the time of the inspection.

People’s experience of using this service:

•People were protected against abuse and discrimination and their rights were upheld.

•Staff received training and were supported to ensure they had the skills, knowledge and confidence they needed to perform their roles effectively.

•People did not always receive services which were responsive to their needs as they had not always been supported to have access to person centred activities which met their needs, in particular for those who lived with dementia.

•People were enabled to have choice and control of their lives and staff supported people in the least restrictive way possible; the registered providers policies and process supported this practice.

•Staff treated people with kindness and their dignity and privacy was respected.

•People and their relatives were involved in reviewing their care and making any necessary changes.

•A process was in place which ensured complaints could be raised. Concerns were acted upon and lessons were learned through positive communication.

•The service was consistently managed by an established registered manager and the registered provider had systems in place to monitor the quality of the service. Actions were taken and improvements were made when required.

Rating at last inspection:

Good (report published June 2016)

Why we inspected:

This was a planned inspection based on the rating at the last inspection. The service remained rated good overall.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

9 June 2016

During a routine inspection

This was an unannounced inspection carried out on 9 June 2016.

Noss Mayo Residential Home can provide accommodation and personal care for 14 older people and people who live with dementia. There were 14 people living in the service at the time of our inspection all of whom were older people.

There was a registered manager in post. 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.

Staff knew how to respond to any concerns that might arise so that people were kept safe from abuse including financial mistreatment. People had been helped to avoid the risk of accidents and medicines were managed safely. There were enough staff on duty and background checks had been completed before new staff were appointed.

Staff had received training and guidance and they knew how to support people in the right way. People had been assisted to eat and drink enough and they had been supported to receive all of the healthcare assistance they needed.

Staff had ensured that people’s rights were respected by helping them to make decisions for themselves. The Care Quality Commission is required by law to monitor how registered persons apply the Deprivation of Liberty Safeguards (DoLS) under the Mental Capacity Act 2005 (MCA) and to report on what we find. These safeguards protect people when they are not able to make decisions for themselves and it is necessary to deprive them of their liberty in order to keep them safe. No one living in the service was being deprived of their liberty and so the registered manager had not needed to seek any DoLS authorisations.

People were treated with kindness and compassion. Staff recognised people’s right to privacy, promoted their dignity and respected confidential information.

People had been consulted about the care they wanted to receive and they had been given all of the assistance they needed. This included people who lived with dementia and who could become distressed. People were supported to pursue their hobbies and interests and there was a system for resolving complaints.

Quality checks had been completed to ensure that people received the facilities and services they needed. Good team work was promoted and staff were supported to speak out if they had any concerns because the service was run in an open and inclusive way. People had benefited from staff acting upon good practice guidance.

8 July 2014

During an inspection looking at part of the service

We visited the home to check if the provider had made any of the required improvements to the issues we highlighted during our last inspection of the service completed on 20 May 2014.

The summary is based on a review of the action plan sent to us in response to our last inspection, our observations during our visit, our discussions with people who used the service, a visiting relative and the staff who supported them.

We also looked at people's care records, management records and other documentation. A single inspector carried out this inspection.

During our inspection we focused on a key question we always ask; is the service responsive?

Below is a summary of what we found. If you want to see the evidence supporting the summary please read the full report.

Is the service responsive?

We found the provider had taken action to install appropriate curtain screens in three rooms that people shared at the home. This ensured people's dignity could be better respected when they received personal care or wanted privacy in their room. One person who shared a room said, 'I like the curtains. They (the curtains) are easy to use and we can still see each other when we choose to.' A relative told us. 'The privacy curtains look good. I think this is an improvement.'

We also found the manager had involved people in the development of their individual care plans and any decisions regarding the arrangements in place for their care. For example, people and their representatives had been involved in care plan reviews.

One person said, 'I feel like I am home here. I am involved in things as much as I want to be.' A relative commented. 'We as a family feel involved and would shout up if we felt there were any areas we had not been consulted about.' The relative also told us, 'I know they (staff) have been updating care records and the manager has involved me as the main family contact in the process recently.'

20 May 2014

During a routine inspection

Below is a summary of what we found when we inspected Noss Mayo Residential Care Home on 20 May 2014.

The summary is based on our observations during the inspection, speaking with people who used the service, their relatives and the staff supporting them. We also looked at people's care records and other documentation.

If you want to see the evidence supporting our summary please read the full report.

During our inspection we focused on our five questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

When we visited there were 13 people living at the home. We spoke with three people and also observed how staff provided care and support to people who lived in the home. This was because some people either chose not to speak with us or had problems with their memory and could not tell us directly about their experiences of the care they received.

A single inspector carried out this inspection. During the visit we also spoke with a visiting relative, the manager, home owner and five staff members.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and staff told us.

If you want to see the evidence supporting the summary please read the full report.

Is the service caring?

Throughout our inspection we observed staff were respectful and sensitive in their approach to meeting people's needs. People told us things like, "The care here at the home is good' and 'I enjoy living here. The staff are always about and they listen when we call for help.'

Is the service responsive?

The manager and home owner confirmed any concerns raised with them had been addressed straight away and we found responses had been open and timely. People could therefore be assured that informal concerns were addressed and systems were in place to make sure more formal complaints would be investigated in the right way.

When we spoke to people about their involvement with their care plan one person commented, 'I know the staff keep a check on things but I haven't been to any meetings to talk about my care. I'm not really bothered because they sort it out.'

Records showed people were involved in an assessment either before they moved into the home or as soon as they moved in. Care plans were created with people based on the assessment information. This included people's individual choices about how they wanted to be cared for when they moved into the home.

However, information did not show how people had been involved in the ongoing development of their care plan or any changes made to them. For example people had not been involved in their care plan reviews.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the involvement of people in identifying and agreeing any changes in the delivery of their care.

Is the service safe?

People told us that they felt safe living at the home. We saw safeguarding procedures were in place and that staff understood how to safeguard the people they supported.

The manager had policies and procedures in place in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards although no applications had needed to be submitted. This meant people were protected against the use of unlawful or excessive control or restraint because the provider had made suitable arrangements.

The service was safe, clean and hygienic. Equipment was well maintained and serviced regularly therefore did not put people at unnecessary risk.

Is the service effective?

We found people's nutrition was assessed and dietary needs were monitored to ensure people were not at risk of malnutrition.

We saw people were supported to have a choice of food and drinks and staff encouraged people to make decisions about their meals for themselves. Where people needed access to a special diet they received food appropriate to their needs.

We also found mobility and equipment needs had been identified in care plans where required.

Is the service well led?

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a consistent service at all times.

The service worked well with other agencies and services to ensure people received their care in a joined up way. The manager had a quality assurance system and records seen by us showed that any shortfalls identified were addressed in the right way.

3 March 2014

During an inspection looking at part of the service

When we visited the service in November 2013 we asked the provider to make improvements in staffing levels. This visit was to look at those improvements.

On the day of our visit 13 people were living at the home. The majority of people had a memory loss.

We spoke with two people who lived in the home and two members of care staff. The manager was not available to speak with on our visit.

The provider had sent us an action plan telling us what they were going to do make the improvements required. We found improvements to the staffing levels in the service had been made during the daytime.

The people we spoke with told us there were sufficient staff on duty to meet all of their needs. One person told us, 'The girls have got more time for us now.'

6 November 2013

During a routine inspection

When we visited, 13 people were living in the home. We looked at the care of three people in detail, spoke with five people who lived there as well as staff, the manager and two relatives of people in the home. Some people were unable to speak with us and we used our observations to understand about the care they received. We also looked at records and observed how staff supported the people living in the home.

We saw people being asked for permission/consent by staff before they undertook any care needs or treatment and staff respected the response they received.

However, we found no evidence that people had given their consent for photographs to be taken or care staff to give them their medicines.

People appeared well cared for and relaxed. The people we spoke with told us they were happy living in the home. One person told us, 'I like it here.' A relative we spoke with said, 'They're so kind to xxx.'

People received care and support although this was not always reflected in their care records.

Medicines were stored, administered and disposed of safely.

Because only two care staff were on duty during the day, we found that one person in the lounge was being relied on to use the call bell for staff's attention if it was required. People's psychosocial needs were not always met.

There were systems in place to monitor the quality of service given to people. People we spoke with told us they could raise any issues with the manager and felt confident they would be dealt with quickly.

28 March 2013

During an inspection looking at part of the service

The provider had sent us an action plan telling us what they were going to do to make sure they were compliant with the two standards we had set compliance actions against when we visited in October 2012.

We did not speak with people who used the service. This was because we were looking at the premises, checking records and speaking with staff.

The provider had made improvements to the way it managed infection control relating to the routine cleaning of commode pots. There was a risk assessment in place regarding the cleaning of them.

Care records had improved since we visited in October 2012. We saw staff supervision sessions and staff meetings had been recorded.

8 October 2012

During a routine inspection

We visited the home as part of our scheduled inspections for the year. In addition, we looked at whether the service was now compliant following the actions we asked them to take during our last inspection.

During our visit we looked at records. These included care plans and minutes of meetings. We spoke with care staff, people who use the service and people who visit the service. We also sat and watched care staff delivering care to people in the home.

People told us they liked living in the home and staff were kind and friendly. One person told us, 'I love it here.'

People told us they felt safe in the home. A relative told us, 'I've never heard anyone raise their voices to the residents.' Care staff knew how to protect the people in the home and who to contact if they had concerns.

We found the home was not taking sufficient care to protect people from the risk of infection but the provider had improved the heating in the lounge so that people were warmer.

We saw evidence that care staff received training and support to do their jobs and people told us they felt the staff knew what they were doing.

People felt they were asked about their opinions in the running of the home by the manager and felt confident taking any concerns directly to her.

Records, although kept securely, were not always accurate or updated as quickly as they should have been.

7 March 2012

During a routine inspection

On the day we visited one of the owners, the registered manager and two members of care staff were present. There were fourteen residents living in the home.

People told us they liked living in the home and staff were kind and friendly and knew what they were doing. However, one person said they didn't like being called 'darling' by care staff and we told the manager about this.

The manager told us the home could always get the help of health professionals whenever they needed it and we found evidence in the care plans that district nurses and doctors visited people when it was necessary. People told us they were not always involved in their plan of care.

Everyone felt safe living in the home and when we asked them what they would do if they did not, they told us they would tell the manager who they felt would do something about it. Care staff knew the different forms of adult abuse and what to do if they suspected it.

We heard one of the people say that they felt cold and when we asked if they frequently felt cold that told us they did in the cold weather.

We saw staff caring for people in a dignified manner and people were very complementary of the care they received from staff. One person told us 'We all get treated very well.'