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The Mount & Severn View Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 September 2018

This inspection took place on 19 and 23 July 2018 and was unannounced.

The Mount & Severn View is registered to provide accommodation with nursing and personal care to a maximum of 58 people, some of whom are living with dementia. There were 49 people living at the home on the day of our inspection. People’s bedrooms are over two floors and the first floor is accessed by stairs or a passenger lift. People have access to communal areas within the home and access to the home’s gardens.

A registered manager was not in post at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection on 24 August 2017 we rated the service as requires improvement and we found one breach of regulation of the Health and Social Care Act 2008. We asked the provider to take action to make improvements to ensure there were sufficient numbers of staff, people received the care and support they needed and were treated with respect and consideration at all times. We also asked the provider to make improvements to their arrangements to ensure people were protected from abuse and not restrained unlawfully. We asked the provider to send us an action plan. At this inspection we found that some improvements had been made, however further improvements were required.

The systems the provider had in place to identify areas that required improvement and to drive those improvements were ineffective in ensuring the experiences of people had improved since the last inspection.

Staffing numbers had been increased, however people still did not receive care in a timely manner.

Risks to people were assessed and minimised however environmental risks had not been considered.

People were not always treated with dignity and respect and their needs were not always responded to in a timey manner.

Complaints were investigated however there was no system in place to address informal grumbles.

Infection control measures were in place however they had not prevented malodours in some areas.

People were safeguarded from the risk of abuse and their medicines were stored and administered safely.

The principles of the Mental Capacity Act 2005 were followed to ensure people who lacked capacity consented to their care and support at the service.

People were cared for by staff who were trained and supported to fulfil their roles.

People’s needs were assessed and they had access to health care agencies when they became unwell or their needs changed.

Inspection areas

Safe

Requires improvement

Updated 25 September 2018

The service was not consistently safe.

Although staffing numbers had increased people still had to wait for their care needs to be met.

Individual risks had been assessed however risks within the environment had not been considered.

People’s medicines were stored and administered safely.

People were safeguarded from abuse and staff were employed through safe recruitment procedures.

Accidents were investigated and lessons learned when things went wrong.

Effective

Requires improvement

Updated 25 September 2018

The service was not consistently effective.

Some areas of the environment required maintenance to ensure it was safe for its intended purpose.

The principles of the Mental Capacity Act 2005 were followed.

People were cared for by staff who were trained and supported to fulfil their roles.

People’s needs were assessed and they had access to health care agencies when they became unwell or their needs changed.

People were supported to eat and drink sufficient amounts to remain healthy.

Caring

Requires improvement

Updated 25 September 2018

The service was not consistently caring.

People were not always treated with dignity and respect.

People’s right to privacy was upheld.

People were involved in decisions about their care.

Responsive

Requires improvement

Updated 25 September 2018

The service was not consistently responsive.

People’s needs were not always responded to in a timely manner.

Formal complaints were responded to however people’s informal issues were often left unresolved.

People were offered activities within the communal areas.

People’s end of life wishes were gathered and responded to at the required times.

Well-led

Requires improvement

Updated 25 September 2018

The service was not consistently well led.

The provider’s system to ensure the quality of care improved for people had been ineffective.

Staff worked in partnership with other health and social care colleagues.

There was a manager in post who was yet to register with us.

Staff told us that they received support and guidance from the manager.