Mahogany Care Home

Mahogany Care Home provides residential and nursing care for up to 51 people, some of whom are living with dementia. The accommodation is on the ground floor and consists of en-suite bedrooms, two large communal lounges and a dining room. There is a large internal courtyard/garden. At the time of this inspection there were 49 people living at the home.

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

Leadership at the home had been inconsistent due to the lack of a stable management team. This had led to a shortfall in the oversight of a number of areas, such as staff supervision. However, the recent appointment of a new registered manager had increased staff morale and they had already put plans in place to address areas where issues had been noted and had started to make the required improvements. Quality assurance systems to monitor the service were in place. There were procedures to ensure any accidents, incidents or complaints were fully investigated and people and relatives involved and informed of the outcome. Staff understood how to manage risks to people’s health and wellbeing.

Staffing levels were allocated based on people's needs, with regular agency staff used to cover staff absences. An activities coordinator had recently been recruited. Pre-employment checks ensured staff were suitable to work in the care service. Staff had completed training in safeguarding and knew how to recognise and report abuse or neglect. Relatives we spoke with were happy with the home and its staff.

We found medicines were managed safely across the home. However, we recommend reviewing and updating all people’s medicines information and care plans to ensure they are up to date and accurate.

The home was clean and well maintained. Staff followed good infection control practices.

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 (report published 23 December 2019).

Why we inspected

This inspection was prompted by a review of the information we held about the service. This report only covers our findings in relation to the key questions of Safe and Well led. 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 remained the same This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Mahogany Care Home provides residential and nursing care for up to 51 people, all on one ground floor level. The home has two large communal lounges and dining area. There is also an internal courtyard and garden area with seating. At the time of the inspection there were 49 people living at the home.

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

The service had an open and supportive culture. Systems were in place to monitor the quality and safety of care delivered. There was evidence of improvement and learning from any actions identified.

The premises were clean, homely and well maintained. People’s medicines were managed safely.

Staff had awareness of safeguarding and knew how to raise concerns; steps were taken to minimise risk where possible.

We observed a relaxed atmosphere throughout the home where people could move around freely as they wished. There were sufficient numbers of trained staff to support people safely.

Recruitment processes were robust and helped to ensure staff were appropriate to work with vulnerable people.

People’s needs continued to be thoroughly assessed before starting with the service. People and their relatives, where appropriate, had been involved in the care planning process.

Staff were competent and had the skills and knowledge to enable them to support people safely and effectively. Staff received the training and support they needed to carry out their roles effectively. Staff received regular supervisions and appraisals.

We observed many caring and positive interactions between staff and people throughout the inspection. Staff had formed genuine relationships with people and knew them well and were seen to be consistently caring and respectful towards people and their wishes.

Staff supported people to access other healthcare professionals when required and supported people to manage their medicines safely.

Staff worked with other agencies to provide consistent, effective and timely care. We saw evidence that the staff and management worked with other organisations to meet people’s assessed needs.

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.

The provider and registered manager followed governance systems which provided effective oversight and monitoring of the service.

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 on 08 November 2018). 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.

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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

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.

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 were sufficient numbers of staff on duty to meet people’s needs safely. Relatives said there were occasions when there were not enough staff, but said staff went ‘beyond the call of duty’ to ensure there was no impact to people or the quality of care provided.

We found medicines were stored, handled and administered safely. Staff responsible for administering medicines were trained and regularly had their competency assessed.

There were capacity assessments in place and the correct procedures had been followed to ensure people were not unlawfully deprived of their liberty. We saw advocates were involved in people’s care when there was no nearest relative to act on their behalf and best interest meetings were underway to support best interest decision making.

All new staff received an induction, which included an identified staff member to act as a mentor to support the induction booklet, time shadowing experienced staff and staff completed the care certificate. Staff did online training and had practical sessions in first aid, fire and moving and handling. Staff confirmed they received regular supervision and annual appraisals, which along with the completion of daily flash meetings and monthly team meetings, ensured they were supported in their roles.

The feedback received was positive regarding the mealtime experience and the choices offered at each meal. The chef and kitchen staff demonstrated oversight and effective systems to manage people’s dietary needs.

People and their relatives spoke highly of the staff and care provided. Staff treated people with dignity and respect and promoted people’s independence. People confirmed they were given choices and their consent was obtained prior to staff undertaking care tasks.

There were daily activities at the home and people and relatives told us there had been an increase in outings over the past few weeks. We observed pamper sessions, arts and crafts and a coffee morning whilst undertaking the inspection.

Care plans contained sufficient information to mitigate risks but were not person centred and did not detail people’s personal preference or wishes. There were inconsistencies across the records which meant it was difficult to ascertain the care provided and personal care records didn’t lend themselves to determine how frequently people were being offered baths and showers or the time of day these were being offered.

People and their relatives were positive about the current management arrangements but expressed concerns about the frequency managers had changed at the home. Regular meetings were held to communicate the changes and people and relatives told us they could express their views.

The provider had a range of systems and procedures in place to monitor the quality and effectiveness of the service. Audits were completed and covered a wide range of areas including environment and infection control, safeguarding and dignity of care, medication, care files, and nutrition. We saw evidence of action plans being implemented and timescales identified to address issues found.

At our last inspection on 01 February 2016, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014in respect of; safe care and treatment (two parts of the regulation), staffing and good governance.

The home was rated as requires improvement overall and in the key lines of enquiry (KLOEs) for; safe, effective, responsive and well-led. The home was rated as good in caring.

At this inspection we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in regards to; person-centred care, dignity and respect, governance and staffing (two parts of the regulation). We also made a recommendation in relation to covert medicines. You can see what action we told the provider to take at the end of the full version of this report.

Mahogany Care Home provides residential or nursing care for up to 51 people and benefits from all ground floor accommodation. There were 44 people living at the home at the time of our inspection, including people living with a diagnosis of dementia. The home is situated in a residential area close to Wigan town centre and local amenities.

At the time of the inspection there was a registered manager in post, but they had resigned and were working their last day of notice at the time of the inspection. 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.

At the time of the inspection, the head of quality assurance, regional support manager and interim manager were facilitating our visit. A manager had been appointed and was expected to commence in post in August 2017. The interim manager would be providing daily oversight until the new manager arrived at the home.

People who used the service and the majority of relatives told us they felt the service was safe. The provider was no longer in breach of regulation 12; safe care and treatment which meant they were now meeting the requirements of this regulation.

We received a poor response from people living at the home, staff and visitors with regards to the staffing levels at the home. Whilst a formal dependency tool was used to determine staffing numbers, the agreed numbers of staff on duty each day was not consistent. We were told this impacted on the timeliness of the care provided which had compromised people’s dignity.

There were appropriate risk assessments in place with guidance on how to mitigate risk. Staff recruitment was robust with appropriate checks undertaken before staff started working at the home.

Staff demonstrated a good understanding of abuse and local safeguarding procedures.

We found DoLS (Deprivation of Liberty Safeguard) applications had been made as required but staff were not always aware of the people subject to DoLS.

Staff training had improved since our last inspection, but supervision and appraisal had previously been raised as an area of concern and the provider could still not demonstrate that this was being provided as regularly as outlined in the the homes supervision policy and procedure.

We found the staff had worked closely with other health professionals and appropriate referrals had been made when concerns were identified.

People confirmed they were given choices regarding their care. However, the care plans we looked at did not demonstrate that people had been involved in the planning of people’s care and whilst reviews were done, they were signed off by staff and did not involve people living at the home. People told us they didn’t know what a care plan was.

People and staff spoke fondly of each other. People we spoke with gave staff high praise and said that their privacy and dignity was promoted. However, we were informed of occasions when people’s dignity had been compromised as a consequence of staffing levels. We also saw missed opportunities during the inspection to engage people in conversation.

There was an activities coordinator employed at the home and although there were no trips out at the current time, people told us they valued walks out in to the community and local shops with the activity coordinator. There was an activity programme that people could engage with if this was their choice to do so.

People, visitors and staff we spoke with during the inspection were uncertain of the management arrangements at the home. Staff morale was low and staff expressed not feeling valued or listened too.

We found the management to be open, honest and transparent regarding the home’s current position and they had a clear identified plan to address the shortfalls in a structured and timely way. A home audit had been done prior to our inspection visit and the shortfalls and action plans had been shared with us prior to our inspection. This meant the management were addressing shortfalls and putting measures in place to improve the quality of the care provided to people.

We last inspected this home on 20 March 2014, when we found the service to be compliant with all regulations we assessed at that time.

Mahogany Care Home provides residential or nursing care for up to 51 people and benefits from all ground floor accommodation. There were 42 people living at the home at the time of our inspection, including people living with a diagnosis of dementia. The home is situated in a residential area close to Wigan town centre and local amenities.

At the time of our inspection, there was no registered manager in post. The previous manager had been in the process of registering with the Care Quality Commission but had left the post suddenly on 06 January 2016 and retracted their application to become the registered manager.

At the time of the inspection, the operations manager was overseeing the daily management of the home and informed us that a new manager had been recently appointed. The new manager would be commencing at the home when all recruitment documentation had been received. 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.

During the inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014in respect of: Safe care and treatment; Staffing; and, Good governance. You can see what action we told the provider to take at the back of the full version of this report. We also made three recommendations.

People had risk assessments in place to help ensure any risks were minimised. We saw appropriate actions had been taken to help mitigate risks following incidents and to reduce the potential for further re-occurrence.

During the inspection we checked to see how the service managed and administered medication safely. We found people were not always protected against the risks associated with medicines, because the provider could not consistently demonstrate there were arrangements in place to manage medicines safely. We found medication that had not been available for one person since 27th January 2016. We also identified a person whose cream had been applied inconsistently and not in line with their prescription. We also found that a person had been receiving creams without sufficient records being kept.

We saw one person’s nutritional needs were met through the use of a Percutaneous Endoscopic Gastrostomy (PEG) feed. We saw that the person commenced their feed in the required position but we observed that this person did not maintain the position and had slipped further down the bed. The staff call bell was not in reach of the person to alert staff. This meant by not maintaining the required angle during the feed, this person was exposed to a risk of aspiration. We alerted a member of staff about this and asked that the person be repositioned. We received confirmation following the inspection that hourly observations had been implemented whilst the person was receiving the PEG feed.

Prior to conducting the inspection, we received information of concern regarding insufficient staffing levels during the month of December 2015. The operations manager acknowledged this during our inspection but confirmed that staffing levels had been increased since the previous manager’s departure. During the inspection, we found sufficient numbers of staff to meet people’s needs but questioned whether staffing levels were sustainable and would be maintained when the new manager was in post. We made a recommendation that the provider implements a dependency tool to ensure that sufficient number of suitably qualified and experienced staff are deployed within the service to meet people’s needs.

People and their relatives told us they felt safe and staff understood safeguarding process. We saw procedures in place for staff to follow.

We found robust recruitment procedures were in place. Each personnel file confirmed appropriate checks had been undertaken prior to staff commencing in employment at the home. Nurse registration with the nursing midwifery council (NMC) was up to date. However, staff had not consistently received training or supervision and appraisal to support them in their roles.

We saw where people had been deprived of their liberty; applications had been submitted to the local authority for a Deprivation of Liberty Safeguards (DoLS) authorisation. Staff told us they would like training in this area and the operations manager sent us confirmation that this had been scheduled for 29th February 2016.

Everyone we spoke with was happy with the food provided and people were supported to eat and drink enough to meet their nutritional and hydration needs. Any dietary requirements were catered for and people were given regular choice on what they wished to eat and drink. Risk of malnourishment was assessed and acted on.

We observed people living at the home were living with sensory impairment, memory issues or living with dementia. We found the home did not have adequate signage features that would help to orientate people with this type of need. We saw no evidence of dementia friendly resources

or adaptations in any of the communal lounges, dining room or bedrooms. This resulted in lost opportunities to stimulate people as well as aiding individuals to orientate themselves within the home. We have made a recommendation in relation to environments. The operations manager contacted us following the inspection to identify how they had commenced addressing this recommendation.

People and relatives consistently told us that staff were kind and caring. There was a positive caring culture and people’s independence was promoted and their privacy and dignity maintained. Staff were passionate about providing high quality care and were engaged with end of life training.

Care plans were comprehensive and of a good standard but we found inconsistencies with people and family engagement with some care plans being nurse-led. All care plans provided clear instructions to staff of the level of care and support required for each person and were reviewed and updated responsively to meet people’s changing needs.

During our inspection, we checked to see how people were supported with interests and social activities. On the day of our inspection we did not observe any activities being undertaken with people. We were told by staff and management that there was a volunteer that attended the home as the activities coordinator was currently off and returning in May 2016.

We found, the care and support offered to people living with a sensory impairment was not always provided to meet their individual needs. We recommended that management should explore further information from a reputable source to assist them in supporting people living with a sensory impairment.

We saw the complaints procedure displayed around the home and saw the complaint received had been responded to in the required time frame.

We found all the records we looked at were structured and organised which assisted us to find the information required efficiently. This made information easy to find and would assist staff if they were required to find information quickly.

The management had not undertaken surveys with people, relatives and staff but feedback had been sought at meetings and there was a suggestions box in the foyer of the home.

We saw the provider undertook quality assurance visits to measure and monitor the standard of the service to drive improvement. Although there were systems to assess the quality of the service, we found the breaches of the regulations we have identified had not been exposed by the provider audit.

Providers are required by law to notify CQC of certain events in the service such as serious injuries, deaths and deprivation of liberty safeguard applications. Records we looked at confirmed that CQC had not received all the required notifications consistently and in a timely way. We had also asked the previous management for a provider information return (PIR) which had not been received to support the planning of the inspection.

Staff spoke positively about the operations manager and the improvements that had been made since they were overseeing the daily management of the home. We provided feedback to the operations manager and we found they listened to our findings and demonstrated a commitment to improve standards within the home and support the new manager to achieve this. The operations manager was transparent and acknowledged where the home had been and identified the action they had taken to address the issues raised.