2 August 2019
During a routine inspection
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.