Archived: Montague House

Updated 17 September 2019

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 was carried out by one inspector.

Service and service type

Montague House 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. The registered manager was not at the service at the time of the inspection.

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. 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 four people who used the service about their experience of the care provided. We spoke with three members of staff, the provider, and deputy/acting manager. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included two 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.

Updated 17 September 2019

About the service

Montague House is a residential care home providing personal and nursing care to 16 people aged 65 and over at the time of the inspection. The service can support up to 19 people.

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

People told us they felt safe at the service and like living there. However, we found that people were not always safe. People’s medicines were not managed safely or in line with good practice. Risks to people were not always updated or considered when changes were made to support. Staff understood their responsibilities to safeguard people from abuse. Until recently there had not been enough staff to keep people safe, staffing numbers had been increased as requested by the local authority safeguarding team.

The registered manager had been absent from the service for some time at the time of the inspection. A large amount of information could not be found or was incomplete. Audits had not been completed and staff recruitment and training files were incomplete. Staff did not always have the training they needed to support people. The provider had relied wholly on the registered manager to keep oversight of the service and was unaware of any of the issues identified at this inspection. Staff told us the deputy/acting manager was supportive and open to ideas, however this had not been true of the registered manager.

Systems were not in place to gain feedback from people about the service. People told us they would tell staff if they were unhappy but records relating to complaints could not be found. People were treated with care by staff who knew them well and who tailored their interactions to each person. People could have visitors at any time and enjoyed taking part in a range of activities.

People received care based on their needs and preferences, however care plans did not always contain the most up to date information. People had access to healthcare as required. There was a choice of food available and it was offered in a way which met people’s health 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.

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 (published 06 July 2018.).

Why we inspected

The inspection was prompted due to concerns received about safeguarding concerns and allegations of financial abuse. A decision was made for us to inspect and examine those risks.

The inspection was prompted in part by notification of a specific incident. Following which a person using the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to safe management of medicines, management of risk, management of complaints, staff training and the overall management of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.