Mabbs Hall Care Home

Updated 11 August 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

The inspection was carried out by 2 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

Mabbs Hall 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. Mabbs Hall 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 inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. 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 used all this information to plan our inspection.

During the inspection

We spoke with 5 people who lived at the service, however, not all people were able to tell us about their experience of living in the home, so observations of care and support were also made. We spoke with 11 relatives and had contact, both during the inspection visit and via email afterwards, with 21 staff members. These included the registered manager, the deputy manager, nursing staff, care staff, catering, housekeeping and maintenance staff. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

A selection of records was also viewed, and these included the care plans and associated records for 4 people who used the service. The medicines records for 4 people were also assessed. The governance records viewed included policies and procedures, staff recruitment records, training information, quality monitoring audits and maintenance records.

Updated 11 August 2023

About the service

Mabbs Hall is a care home which at the time of inspection was providing personal and nursing care to 20 older people, some of whom were living with dementia. The service can support up to 29 people.

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

Not everyone had a sufficient and detailed care and risk management plan in place. This meant staff had not been provided with formal guidance as to the care support needed and how to identify specific risks to people's health, welfare and safety.

People mostly received their medicines as prescribed. However, we identified an area for improvement around the storage of prescribed creams and stock levels of a prescribed pain relief patch for 1 person.

Staff did not always feel valued and supported by the registered manager. Some relatives felt communication was not always effective between themselves and the management team at Mabbs Hall.

Whilst audits in place had identified some of the shortfalls we found at this inspection, progress on rectifying these concerns was slow.

Whilst people were supported by kind and caring staff, there were insufficient numbers of staff to meet people’s needs in a timely manner.

People were protected from the risk of abuse because the provider had effective safeguarding systems in place. Overall, effective systems were in place to prevent and control the spread of infection.

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 rating for this service was good (published 17 April 2019)

Why we inspected

The inspection was prompted in part due to concerns received about a lack of personal care, people experiencing delays in receiving personal care, medicines concerns and language barriers with care staff employed. A decision was made for us to inspect and examine those risks.

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 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 Mabbs Hall on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the safe management of risk and medicines as well as the providers 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.