Mountjoy Road

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to medicines management and good governance.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Shortfalls in relation to governance and oversight meant systems and processes were ineffective in ensuring shortfalls were consistently identified, lessons learnt and improvements made. The registered manager told us they shared lessons learnt with staff during staff meetings, however due to shortfalls in the quality assurance processes this was not effective in supporting continued learning and driving improvement. However, there was a clear process in place for accidents and incidents. They were appropriately recorded and reported to the relevant agencies, for example, the Local Authority and CQC.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Staff worked with external health professionals such as District Nurses to support people. However, there were significant shortfalls in relation to oversight of partnership working, monitoring people’s risks and the accuracy of records. This meant we could not be assured information being shared was detailed, up to date and reflective of people’s current needs, to support their safety.

There was a robust pre-admission process in place which included an assessment, face to face meeting and visits to the service, to support safe admissions.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. However, recording in relation to people’s DoLS required improvement.

Systems and processes were in place to ensure people were safeguarded from the risk of abuse. Staff had completed safeguarding training and knew how to identify signs of abuse and report concerns. The registered manager had knowledge of the safeguarding process and their responsibility to report to the Local Authority and CQC. There had not been any recent safeguarding incidents at the service.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Whilst processes had been followed to ensure people were not unlawfully deprived of their liberty we found shortfalls in relation to records. There were no care plans or risk assessments in place in relation to 3 people’s DoLS. In addition, not all staff knew who had a DoLS in place. This meant there was a lack of guidance to support staff in protecting vulnerable people’s legal rights and ensuring safety.

The provider did not work well with people to understand and manage risks. People’s needs were not met safely.

Risks to people were not safely assessed, monitored and managed. People did not have risk assessments and care plans in place to enable staff to support them safely and meet their needs. For example, people did not have care plans regarding their learning disability and/or autism, or for other specific health conditions. Two people diagnosed with diabetes did not have care plans and risk assessments in place to guide staff in the safe monitoring and management of this. Staff were not always aware of the signs and symptoms of deterioration in relation to diabetes. One staff member told us, “Well I don’t suppose I would [know about diabetes]. I wouldn't know what [signs of deterioration] would look like, but I'd know if they were unwell." In addition, 1 person did not have appropriate care plans and risk assessments in place to guide staff in safely supporting their mental health condition. Where limited information was available this was often out of date for review, inaccurate and conflicting. There was no evidence of people’s involvement in reviewing their risks. Where monthly reviews had taken place, the registered manager had done these independently and made no changes or updates.

The provider mostly detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment was homely, decorated nicely and in a good state of repair. Personal emergency evacuation plans were in place to support people to safely evacuate in the event of a fire. Health, safety and equipment checks were in place, for example, gas safety and stair lift checks. However, during the first day of assessment the door leading to outside of the service was found to be unlocked during the morning. This meant people could leave or enter the service unnoticed. The registered manager was informed about this, however, later the same day, the door was again unlocked. Furthermore, despite the concerns being shared twice during the first site visit, the following day when inspectors arrived the door was unlocked and the service accessible for people to walk into and out of. Following the assessment the provider informed us they had taken action to address this.

There were enough staff to meet people’s needs. Staff participated in supervision sessions. However, the provider did not ensure staff were always appropriately trained to support the safe delivery of care.

There were enough staff at the service. They responded to people without delay. Staff participated in supervision sessions and told us they felt supported. Mandatory training compliance was high and included learning disability training. However, staff did not always receive training for people’s specific health conditions, for example, stoma care. Following an initial demonstration at from the hospital in 2019 there had been no further refresher training provided to staff, some of whom were not employed at the time of the initial demonstration. In addition, the registered manager told us she did not check staff competencies regarding stoma care.

Safe recruitment processes were in place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and tidy throughout. Staff were observed cleaning and there were no malodours. One relative told us, “The home is always spotlessly clean and well maintained.” PPE was readily available when it was needed.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were stored securely in the medicines cabinet and there was good stock availability. All medicines in use were within their expiry dates and stock counts were accurate. However, excess medicines and those that were no longer required were not stored in line with the policy.

The Medicines Administration Records (MARs) reviewed had been completed with records of medicines administration, and no gaps were found. However, the MARs did not contain all the required information to support the safe administration of medicines, such as allergy status and medicines cautionary labels, and records for paracetamol administration were sometimes unclear.

People’s profile pages and medication sheets was not always accurate or lacked sufficient details. Protocols for medicines that were taken ‘when required’ were available for most medicines, however, they were not person centred and did not provide sufficient information on how the medicines were to be administered safely, or how to manage the condition for which they were prescribed. Care plans to support people with specific medical conditions were not in place.

Where creams had been prescribed, body maps were in place and accurately highlighted to show where the creams were to be applied. There were also risk assessments in place for people prescribed flammable emollients.

Training records were up to date for all staff administering medicines and competency assessments had also been completed for all staff.

There had been no medicines related incidents recorded, and we were told no incidents had occurred.

Medicines audits were completed weekly and monthly. The most recent comprehensive audit had not been effective at highlighting some of issues found during the assessment.