Maesbrook Nursing Home

Updated 12 January 2023

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors and an 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

Maesbrook Nursing 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. Maesbrook Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We also contacted the local authority and Healthwatch to gather their views. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

During this inspection we spoke to 11 people and 12 relatives. We also spoke with 9 members of staff which included the registered manager, administrator, care staff and auxiliary staff. We looked at 5 people’s care plans along with 4 staff recruitment files and, other systems and records used to manage the service.

Updated 12 January 2023

About the service

Maesbrook Nursing home is a care home providing regulated personal and nursing care to up to a maximum of 45 people. The service provides support to older people, people living with dementia, people with a physical disability or sensory impairment and at times younger adults. At the time of our inspection there were 44 people using the service.

The home is large with bedrooms over three floors. There is a large communal lounge, dining room and access to outside space.

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

People were not always supported by enough staff; recruitment plans were in place but the feedback we received was that there was not always enough staff to meet people’s needs in a timely manner. People’s relatives worried the staffing issues impacted on how the staff could effectively meet people’s needs.

Governance systems were not always effective and risks within the accommodation had not been monitored effectively. Concerns had arisen around fire safety and the electrical wiring system which were being addressed.

We found action was not always taken in a timely manner to ensure necessary improvements were made. Feedback was mixed and people, staff and families suggest more discussion time was needed. People and their relatives told us there was limited opportunity to give feedback on their care. The registered manager advised they had plans to improve this.

People received their medicine on time and the building was kept clean. Staff had access to personal and proactive equipment (PPE) to help keep people and themselves safe. The provider worked with outside agencies and could evidence improvements were being made to the environment and care planning process.

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

The last rating for this service was good (published April 2018).

Why we inspected

We received concerns in relation to fire safety and the management of risk. 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 COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Maesbrook Nursing Home on our website at www.cqc.org.uk

Enforcement and Recommendations

We have identified breaches in relation to the staffing levels and the overall governance of the service 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.