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Mahogany Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 8 November 2018

We undertook an inspection of Mahogany Care Home on 26 and 28 October 2018. The first day of the inspection was unannounced and the second day was by arrangement with the management.

Mahogany Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Mahogany Care Home is a purpose-built home and benefits from all ground floor accommodation. The home provides residential and nursing care for up to 51 people. The home has two large communal lounges, a tea room and dining area. There is also an internal courtyard and garden area with seating. At the time of the inspection there were 39 people living at the home.

The home was last inspected on 10 and 14 July 2017, when we rated the home as ‘requires improvement’ overall and in all the key questions. We also identified five breaches in four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person-centred care, dignity and respect, good governance and staffing (two parts of the regulation). We also made a recommendation in relation to covert medicines.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions; safe, effective, responsive and well-led to at least good. We reviewed the progress the provider had made as part of this inspection.

At this inspection, the provider had made significant improvements and addressed four of the five breaches identified in July 2017. We identified one continued breach of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance. You can see what action we took at the back of the full version of this report.

Prior to our inspection, the provider had been open and honest regarding the position of the home and the outstanding actions required. They had provided an updated action plan in August and September 2018 detailing progress made and identified areas where further improvement was required. The issues found during the inspection had already been raised through the providers own internal monitoring system.

At the time of the inspection the home did not have a registered manager. The registered manager had left in August 2018. The home was being supported by a home manager and the providers head of quality and governance at Whilst undertaking the inspection we were informed a new manager had been appointed and they were currently working their notice at another home. We were told they would be applying to register with CQC upon commencing 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.

People living at the home told us they felt safe. Relatives expressed no concerns about the safety of their family members and were positive about the level of care provided. We saw the home had appropriate safeguarding policies and procedures in place, which were aligned with the local authority safeguarding tier system for reporting. Staff had received training in safeguarding vulnerable adults, which was refreshed annually. Staff demonstrated a good understanding of how to identify and report any safeguarding or whistleblowing concerns.

Staff were recruited safely with references from previous employers being sought and DBS (Disclosure Barring Service) checks undertaken. This ensured staff appointed were suitable to work with vulnerable adults.

Staffing levels were determined by the needs of people living at the home and there w

Inspection areas



Updated 8 November 2018

The service was safe.

We found sufficient numbers of staff on duty to meet people’s needs.

Effective recruitment processes ensured only suitable people were employed.

Processes were in place to ensure people’s medicines were managed safely.



Updated 8 November 2018

The service was effective.

The induction was aligned with the care certificate and staff received ongoing support through supervision, appraisal and training.

The provider was adhering to the principle of the MCA (2005) and had effective systems in place to monitor DoLS. Best interest meetings and advocacy involvement were evident.

People’s dining experience was positive and people’s nutritional needs were assessed and provided as per care plans.



Updated 8 November 2018

The service was caring.

People and their relatives spoke positively of the staff and the care provided.

People were treated with dignity and respect and their independence was promoted.

We observed time was given to people to provide support and reassurance when needed.


Requires improvement

Updated 8 November 2018

The rating of this key question remains Requires Improvement.

Care plans were task focused and did not contain sufficient personalised information to demonstrate people's views and preferences were embedded in to care planning documentation.

Global entries were made in daily logs which were not reflective of the care provided. It could not be determined from personal care records how frequently people were offered baths or showers.

There was a clear complaints process that was advertised around the home.


Requires improvement

Updated 8 November 2018

The rating of this key question remains Requires Improvement.

We identified a breach of the regulations meaning the well-led key question can only be rated as requires improvement.

Audits and monitoring tools were in place and used regularly to assess the quality of the service, with action points generated and details of progress clearly documented.

Meetings were held regularly with staff and people who lived at the home to ensure they had input into the running of the home and were made aware of all necessary information.