Mr 'C's

Updated 6 July 2022

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 team was made up of one inspector, an assistant inspector 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

Mr’C’s 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. Mr’C’s is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

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 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. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used this information to plan our inspection.

During the inspection

We spoke to six people who used the service and one relative about their experiences of the care provided. We also spoke with six relatives on the phone. We spoke to 14 members of staff including the registered manager, the manager, deputy manager, care staff, the chef, maintenance man and receptionist. We reviewed a range of records. This included four people's care records and multiple medicine 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, policies and procedures.

Updated 6 July 2022

About the service

Mr C’s is a residential care home providing personal care to up to maximum of 40 people. At the time of our inspection there were 26 people using the service.

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

People and their relatives told us they felt safe living at Mr ‘C’s and spoke positively about the management and the caring culture of the staff.

People were protected from the risk of abuse as staff knew the correct procedures to follow to keep people safe.

The service had infection control processes in place to reduce the risk of people contracting COVID-19. However, during the inspection we observed some staff not wearing their face mask correctly. This was immediately addressed by the manager.

Care records were person-centred and risk assessments provided written guidance for staff on how to minimise or prevent the risk of harm. Systems were in place to manage risks associated with the building and equipment. During the inspection we found missing fixtures and fittings that posed a risk to people’s safety. This was immediately rectified.

People were receiving their medicines safely and improvements had been made to medicine’s management and administration to ensure people received their medicines as prescribed for them.

People and their relatives told us there were enough staff to meet their needs. Staff were recruited safely, and recruitment checks had been completed before staff started work at the service.

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.

People had been asked for their opinions on the quality of the service. Staff had opportunities to discuss the service and voice their opinions. However, some staff told us they did not have formal one-to-one meetings or supervisions to discuss their performance or training needs. We made a recommendation to the provider about this.

Systems and processes were in place to monitor the service and make improvements. The providers checks and audits were effective in identifying shortfalls and action had been taken to rectify these. This ensured good governance of the service and resulted in the service improving since the last inspection.

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 13 April 2021) and there were 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 inspection was prompted by a review of the information we held about this service. During this inspection we also checked the service had followed their action plan and to confirm they now met legal requirements.

This report only covers our findings in relation to the Safe and Well-led key questions, which contain those requirements.

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 requires improvement to good. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mr’C’s 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.