Archived: Mulgrave House Nursing Home

Updated 10 January 2020

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 Care Act 2014.

Inspection team

The inspection team consisted of an inspector, an assistant inspector and a medicines inspector on the first day. On the second day the inspector visited alone.

Service and service type

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

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced on the first day and announced on the second day.

What we did before the 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. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experience of the care provided. We spoke with ten members of staff including the provider, registered manager, two nurses, four care staff and two members of the therapy team.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We observed two professionals who regularly visit the service.

Updated 10 January 2020

Mulgrave House Nursing Home is a nursing home providing personal and nursing care to 30 people aged 65 and over at the time of the inspection. Six of these people were living permanently at Mulgrave House and the others were receiving short term rehabilitation pending a return home or to other support services. The aim was to restore people’s independence so their reliance on services was reduced or removed.

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

There were some minor issues with medicines which the registered manager resolved promptly.

People were safe as staff were able to recognise and report possible signs of abuse or neglect, and these were acted on appropriately. Any lessons learnt were integrated into practice. Risks were managed through personalised moving and handling plans which evidenced equipment and method needed for transfer. We saw evidence of sound practice as care staff were assisted by their therapy colleagues.

Staffing levels were sufficient to meet people’s needs and promote independence for those in receipt of rehabilitation support. They were supported with regular supervision and training. Communication between staff was good. The home was very clean and accessible for people.

The registered manager had a good understanding of best practice supported by colleagues from the multi-disciplinary meetings held regularly at the home. People were able to access health and social care support as needed.

The dining experience was poor on the first day of the inspection but improved significantly on the second day as the registered manager spoke with staff about the issues we raised. 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.

We observed some lovely interactions between staff and people living in the home. Staff were very caring, kind and considerate. Their focus was ensuring people reached their full rehabilitation potential and promoted interaction between people as much as possible. Care documentation was focused on achievement of specific, person-focused goals and was measurable. For people living long term in the home records showed staff knew them well.

Complaints were handled quickly and thoroughly. End of life wishes were considered and documented clearly.

The service was very focused on the rehabilitation service it offered, and this was well received by people. Due to the transient nature of people’s stay it was difficult to implement overall quality assessments but for each person satisfaction questionnaires were completed, and we saw many compliments.

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 15 December 2018) and there were two breaches 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.