Updated 17 June 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 was carried out by an inspector, a member of the medicines team 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
Mahogany Care Home is a care home with nursing care. 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. 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 a new manager had recently been appointed to the service and registered with the CQC.
Notice of inspection
We gave the service 48 hours’ notice of the inspection so that we could check the service was free from any COVID-19 infection.
What we did before the inspection
We reviewed information we had received about the service since the last inspection, which included feedback from the local authority. 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
During the inspection we looked at a variety of records, including multiple electronic care records and risk assessments and three staff recruitment files. We also looked at records relating to the management of the service, including quality assurance tools, policies and minutes of staff meetings. We reviewed the management of medicines. We talked to the manager, deputy manager, regional manager, head chef, three care assistants, and the care home assistant practitioner (CHAP). This role has recently been introduced at the home and is for a senior carer who has undertaken more advanced training which enables them to support the nursing staff.
The Expert by Experience spoke with three people who use the service and six family members. They also observed the lunchtime meal and undertook general observations of how staff interacted with people.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at several other documents, including some policies and supervision records.