Mont Calm Residential Home

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 Inadequate. 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 poor infection control and the maintenance of the environment.

This service scored 53 (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. Lessons were not always learnt to continually identify and embed good practice. We observed the lawn had several dips in the grass and the paving slabs between the 2 sides of the service were not all level which was a trip risk. We saw from incident reports that 3 falls had occurred in the garden from March 2025. Despite this, action had not been taken to address this risk to reduce further risks to people.

We found the analysis for incidents and accidents at night related to the person’s health and not whether there may be a theme around how staff were deployed at night. As such the only note relating to staff was that staff were to be ‘more vigilant’, and we found staffing levels were not reviewed and amended accordingly.

However, we found where incidents occurred, action was taken to review people’s risks assessments. When people had fallen, where appropriate they were referred to the falls clinic for review. We noted 1 person had been moved to the ground floor due to their increased risk of falling.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The service had only admitted 1 person to the service since the last Assessment. We saw the registered manager had undertaken a full review of their needs to ensure they were able to meet their needs. This included inviting the person to visit the home and gaining information around the person’s preferences. Where people were returning to the service from hospital, the leaders consulted with the hospital staff to ensure they had the most accurate information on the person’s increased needs.

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. People told us they comfortable with staff at the service. One told us, “Staff are very good, I feel quite safe.” We saw people looked relaxed in staff presence. Staff were able to describe different types of abuse and how they would report any concerns. We saw that leaders investigated any potential safeguarding concerns and reported to the local authority where appropriate. One senior member of staff told us, “I do the referrals, if someone has a fall or a physical altercation with a resident, any serious injury, if I have any concern.”

Leaders did not always work well with people to understand and manage risks. According to their care plan, 1 person was required to sit on a pressure cushion to reduce the risk of developing a pressure sore. However, we saw the pressure cushion they were sat on had no padding and was flat. This meant the effectiveness of the cushion had reduced. The registered manager replaced this straight away. We saw in another care plan it stated to reduce the risk of choking the person should not be rushed with their meal and for there to be a calm and quiet environment. We observed staff were rushing the person with their meal and the lunch experience was not calm or relaxed.

However, since the last Assessment we found improvements in the management of risk of people’s health conditions. Where people were at risk of constipation, staff were recording bowel movements and reporting any concerns to the leaders. Where people had a pressure mattress, these were set at the correct levels based on their weight. People’s nutrition and hydration needs were being monitored by leaders. Where people had lost weight, we saw they had been referred to health care professionals.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. Whilst there had been some improvements to the environment since the last assessment, we continued to identify concerns. Inside of the service this included but was not limited to, carpets that were degraded and frayed which were a trip hazard, a hot radiator with no cover risking burns, and rusted frames around people’s toilets. We also observed staff left gates open leading to steep staircases and 1 room left open with maintenance tools which was accessible to people that walked with purpose. One of the boiler cupboard was being used for storing bedding however there was a sign in stating that it was not to be used for storage as it was a fire risk.

In the garden the shed was unsecured, and the window was broken. It was used for storing saws, rakes and other sharp garden instruments. There were also hazardous solvents such as garden furniture varnish. There was also a window cracked in the ‘garden’ room which was a risk to people.

We raised all of this with the Provider who took action after the Assessment to address these safety concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. People told us there were not always sufficient staff to support them. Comments included, “I think they’re short staffed, they should have a couple more girls [carer staff] each shift,” and “I asked for a fresh drink at 06.00 am this morning and I didn’t get it until 08.00, she [the member of staff] said she didn’t have time.”

During the assessment we found there were sufficient staff to meet people’s needs. Call bells were answered in a timely way and when people requested support this was given by staff. However, staff we spoke to told us that there are only sufficient staff during the day as night staff were undertaking the majority of personal care for people in the mornings before they went off shift. One member of staff told us, “Usually there are only 3 or 4 people needing to be got up when we come in.” We also noted from care plans that the majority of people were given personal care and dressed before day staff came on duty. The registered manager told us, “I would expect more people to still be in bed.” Leaders had not considered whether more staff were required during the day, so people had more choice of when they wanted to get up.

Whilst there had been improvements with the training since the last assessment, we found some gaps in the training records. There were ancillary staff that had not completed emergency first aid training. A newly recruited care staff had not completed face to face dementia training or ‘Dignity in Care’ training and we found shortfalls in this member of staff’s practice. When asked their understating of dementia, the member of staff told us it was about making decisions for people. This meant people might not receive the care and support they needed if staff did not understand their needs. We fed this back to the registered manager who told us they would address this with the member of staff.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading. Since the previous assessment, we found there had been some improvements with infection control including with the laundry set up. However, we continued to identify concerns with the management of infection, prevention and control.

When we arrived at the service there was a strong smell of urine in various parts of the service including 2 people’s rooms and lounges. The furnishings and fittings were at times degraded making cleaning less effective. This included, but was not limited to, people’s armchairs, carpets and shelves in bathrooms and bedrooms. In 1 sluice room, there was no sink for staff to wash their hands before leaving the room and it was also blocked with cleaning equipment. Although the laundry room now had a space for staff to separate clean and dirty washing, people’s cleanly laundered bedding was being stored in a damp room with no ventilation.

We raised all of this with the Provider who took action after the Assessment to address this.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Since the previous inspection there had been improvements with management of people’s medicines. People’s medicine administration records (MAR) were now electronic. This alerted staff when medicines were due or if any medicines had been missed. Where ‘as and when’ medicine was required, there was guidance for staff on when it needed to be administered. Staff were also required to enter onto the electronic MAR whether the ‘as and when’ medicine was effective. The room where medicines were administered had air conditioning and staff recorded each day what the temperature was. Each MAR had information on how people preferred to take their medicine. Each member of staff administering medicines had been competency assessed to do so.