Background to this inspection
Updated
26 August 2021
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.
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 an inspector and an assistant inspector.
Service and service type
Mavesyn Ridware Residential Home Limited 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.
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.
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 all of this information to plan our inspection. 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.
During the inspection
We spoke with three people who used the service about their experience of the care provided. We spoke with seven members of staff including the registered manager, deputy manager, senior care workers, care workers and a cook. Some people were unable to speak with us about their experiences so we observed how staff interacted with people in communal areas to help us understand the experience of people who could not talk with us. We spoke with two visiting professionals about their experience of working with the service.
We reviewed a range of records. This included three people’s care records and multiple medicines records. We looked at two 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 and registered manager to validate evidence found. We held an online meeting with the registered manager, deputy manager and provider as the registered manager and deputy manager were unavailable on the days of the inspection. We requested additional evidence and documentation from the registered manager that was not available on the days of the inspection and we reviewed this. We spoke with two professionals who regularly visit the service.
Updated
26 August 2021
About the service
Mavesyn Ridware Residential Home Limited is a residential care home providing care to 12 people aged 65 and over at the time of the inspection. The service can support up to 21 people in one building.
People’s experience of using this service and what we found
People continued to be at risk of harm as the registered manager and provider had not assessed and mitigated risks to people. This included risks in the environment of the home as well as risks associated with people’s health and care needs.
Medicines continued to be managed unsafely which meant the provider could not be sure people got the medicines they needed, when they needed them.
People had not been protected from the spread of infection because suitable systems and processes were not in place.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
The registered manager and provider had not implemented systems that were effective in identifying improvements and ensuring changes happened when they were needed. This meant that people continued to receive care that was not safe.
The registered manager and provider had not complied with their lawful duties to notify CQC of required events and had not displayed their current rating at the service.
There were enough staff that had been safely recruited to support people. However, staff did not have the guidance they needed to support people safely.
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 inadequate (published 25 December 2020 with a supplementary report published April 2021) and there were three breaches of regulations.
At this inspection enough improvement had not been made and the provider was still in breach of those regulations with additional breaches of regulations.
This service has been in Special Measures since the last inspection. During this inspection the provider demonstrated that enough improvements had not been made. The service continues to be rated inadequate. Therefore, this service continues in Special Measures.
Why we inspected
We received concerns about a lack of improvement since the last inspection and people continuing to be placed at risk. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. We did not inspect the other key questions. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating 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.
The overall rating for the service remains inadequate.
You can see what action we took at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mavesyn Ridware Residential Home Limited on our website at www.cqc.org.uk.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified seven breaches at this inspection. These breaches relate to safe care and treatment, management and governance, consent, person-centred care, safeguarding people from unlawful deprivations of liberty, failure to display the most recent CQC rating and failure to notify CQC of required incidents.
We took enforcement action to cancel both the manager and the provider's registration with us.
Follow up
We will continue to work with the local authority, other professionals and stakeholders to monitor the service. 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.
Special Measures:
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.