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Archived: Montrose Good

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Inspection report

Date of Inspection: 2 February 2012
Date of Publication: 23 May 2012
Inspection Report published 23 May 2012 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

Our judgement

People do not consistently experience effective and appropriate care, treatment and support that meets their needs.

Overall Montrose Care Home was not meeting this essential standard.

User experience

Two people we spoke with told us that in their opinion there were not enough carer workers at Montrose. They told us that the carer workers had to give lots of time to people who were more demanding, like those that need to be moved using a hoist. One person told us that often meal and medication routines were late because carer workers were assisting certain people who needed more care. Two members of staff that we spoke with confirmed these comments from people.

One person told us they feel lonely and spent much time in their room and carer workers did not take them out. Two other people told us that they were bored as there was nothing to do.

We observed five people sitting in the lounge. They were looking around or sleeping in their chairs with no conversation or stimulation provided by staff.

A relative we spoke with told us of their concerns regarding the lack of stimulation and activities provided at the home.

During our inspection visit we saw a person had bed rails and bumpers on their bed. The person told us they felt safer with bed rails as they had fallen out of bed twice.

A person we spoke with told us they had not had a bath for weeks and did not know when they were going to get one. Another person said they felt that personal care was provided by the staff only as a favour.

During the inspection we noted that several rooms were cold. The people in these rooms told us they felt cold. Whilst in other rooms we noted were extremely warm. The staff we spoke with were not aware of a problem with the heating.

Other evidence

We reviewed four care records at random. Each care record we reviewed had a long term needs assessment which included the person’s life story and future wishes which were written in the first person.

Risk assessments were not completed consistently. A nutritional risk assessment in one person's file showed that body weight was monitored monthly and a significant weight loss had occurred. A referral had been made to a dietician and advice given. However, a falls risk assessment for one person was reviewed monthly and had a high risk score. There was no evidence on the care record what measures were put in place to support and prevent this person from falling. Neither was there evidence that professional advice had been sought.

We saw daily allocation sheets which gave a summary of people’s care and welfare needs. These sheets were used by carer workers for making notes throughout a shift. We were told by the registered manager this information was then used to handover to carer workers on the following shift and the person who delivered the care was responsible for updating the daily notes.

The care plans we reviewed were not updated regularly to reflect current care needs. We did not see that changes that had been highlighted were fed back into the plan of care. For example a person whose daily notes stated that they had been experiencing frequent headaches for which advice had been sought from a health professional; the care plan had not been updated to include and monitor this problem.

We noted that when needs assessments and care plans had been reviewed the comments were generic. For example the comment ‘no change’ was regularly documented when a care plan had been reviewed.

The registered manager told us that the senior staff updated the care plans on a regular basis and a new care planning process was currently being implemented.

We did not see any activities provided for people. We saw an activities programme on the notice board for the week commencing 19 December 2011. We also saw an activities sheet dated 31 October 2011 with no further subsequent recordings. The registered manager told us that due to budget restrictions there was no longer an activities coordinator employed at the home. The deputy manager we saw had set up an activities table in the lounge with jigsaw puzzles, coloured crayons and books for people to help themselves to.

The care staff we spoke with told us there were insufficient staff rostered to provide appropriate care and that staff were working excessive hours to meet people’s needs.