Mount Pleasant House

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 requires improvement. At this assessment the rating has remained 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 the management of safeguarding people from the risk of abuse, good governance and recruitment of fit and proper persons.

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 consistently learn lessons or embed changes into practice following safety incidents. Lessons were not always learnt to continually identify and embed good practice.

Information from previous incidents was not used to improve practice or update guidance for staff. This meant actions were not taken to reduce the risk of similar events happening in the future, leaving people exposed to risk of avoidable harm.

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.

Healthcare professionals such as GP’s and district nurses were contacted when there was a change in a person’s condition.

The local GP practice visited the service regularly to review the healthcare needs of people.

Health professionals told us staff had “done everything they could” for one person and had contacted them when they required support.

Systems to protect people from financial abuse were ineffective and the provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The service held money for people in a locked safe which was accessible by the provider and acting manager. This included money which had been collected through fund raising to be used for residents and money provided to individuals by their next of kin. The system to record the monies received and any transactions was ineffective. The acting manager told us no records were available and was unable to explain how much money each person had or how the money was spent.

The ‘petty cash’ tin contained an empty paper bag labelled with the name of a person and ‘petty cash £50.00 5/7/25’. There was no indication where the money was or for what it had been used. The policy relating to holding people’s money had not been followed and was out of date. The policy stated, ‘written records of all transactions with service user must be maintained’. This meant people may be at risk of financial abuse.

Staff were able to describe what constituted abuse; however, managers had not always considered some incidents as potentially reportable safeguarding issues. Incidents of self-neglect which had impacted on people’s wellbeing had not been reported to the local safeguarding team by the service.

Staff and management did not always work within the principles of the Mental Capacity Act 2005 (MCA). The MCA sets out how to assess and make decisions on behalf of people who lack capacity.

Mental capacity assessments were not consistently completed and those that had been completed were not always accurate. An assessment had been completed which deemed one person not to have capacity regarding personal care. The assessment stated the person could retain information; however, the acting manager told us this was inaccurate and had been completed in error as the person was unable to remember when asked.

A Deprivation of Liberty Safeguards (DoLS) application had been submitted for one person as they were deemed not to be safe to leave the service on their own. This was recorded in daily notes, but no mental capacity assessment had been completed to inform this application.

We reviewed a DoLS authorisation which was in date for one person, and associated conditions had been complied with.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments did not provide staff with accurate information on how to keep people safe. A person who had previously refused to eat did not have a risk assessment for malnutrition. This meant there was a risk further incidents may not be prevented and opportunities to mitigate the risk had been missed.

Falls risk assessments were not accurate and had not been consistently updated when falls occurred. For example, a person was assessed as ‘low’ risk of falls. However, the assessment did not include their previous falls history and other needs that may impact on the risk of the person falling. Another person was identified as being at risk of falls due to attempting to climb the stairs. A sensor had been trialled to alert staff when the person accessed the stairs. This had been unsuccessful, and the sensor was subsequently removed. The person’s care plan included no guidance to inform staff of the actions they should take when the person attempted to use the stairs.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider used a maintenance book for staff to log when things were broken or not working. Issues logged were not always marked as completed. During the assessment a handrail was seen to be broken and was sharp to touch. The maintenance log showed this had been reported on 2 January 2026 but was not addressed in the 10 days prior to the assessment. This meant people were at risk as prompt repairs had not been completed.

Safety checks were completed by external companies. For example, fire extinguishers, hoists and a stair lift were regularly serviced. Checks carried out internally were not always completed, records showed a fire alarm call point test had not been checked for 3months.

Personal Emergency Evacuation Plans (PEEPs) had been completed and regularly updated.

The provider did not always ensure there were enough qualified, skilled and experienced staff. They did not always make sure training was provided in line with requirements. Staff recruitment did not evidence staff were recruited safely. Staff received effective support and periodic supervision. Staff worked together well to provide safe care that met people’s individual needs.

There were gaps in staff recruitment records, and not all staff files contained full employment histories, interview notes and health questionnaires. For example, not all staff had written references on file. The manager told us this was because some references had been given verbally. However, there were no records of the verbal references. The manager told us they would go back to referees to request written references, but this information was not promptly provided. This meant the provider failed to gather the information necessary to establish prospective staff were suitable for employment in the care sector.

People told us call bells were usually answered quickly. One commented, staff come quickly but “can vary”.

There was no system to regularly review people’s needs to ensure sufficient staffing levels overnight. At night there were 2 members of staff on duty, one of these shifts was a ‘sleep-in’. A member of staff told us this could be difficult if people, who needed support from 2 members of staff, requested to use the bathroom at night.

Staff told us they were well supported and received supervision periodically.

Staff had the skills to meet people’s needs, and their planned training was regularly refreshed. However, there was no training relating to supporting people with a learning disability and/or autistic people. This training has been a legal requirement for all CQC registered providers since July 2022.

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 employed housekeepers and cleaning schedules were used to ensure all areas of the service were regularly cleaned. Throughout the inspection, we observed housekeeping staff were busy, and communal areas were clean and tidy. Clinical waste was managed safely. Personal protective equipment such as gloves and aprons was available throughout the service for staff to use.

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.

Medication was stored safely in a locked cupboard. The cupboard was untidy and contained medication that was no longer required. We spoke with the acting manager who addressed this and on the second day of the assessment this had been cleared.

Some people were prescribed medicines to be taken ‘as needed’ (PRN). Information to direct staff on when and how these medications should be given and any associated side effects (protocols) were not always detailed.

When PRN medication had been given staff did not record the reason the person needed the medication and its effectiveness. This meant there was no system to monitor if the medication had worked.

Medication was not always given as prescribed. One person was reported to have been given medication ‘crushed’; this had not been agreed by a doctor or pharmacist to ensure it could be safely administered.

Staff responsible for administering medication were assessed by the acting manager to ensure they could do so safely. Competency assessments were available for 4 members of staff; however, assessments for 2 staff members could not be located within their personnel files. As a result, there was no evidence these staff members had been assessed and deemed competent to administer medication safely. In addition, the acting manager had not completed any specific training to support them in undertaking effective medication competency assessments.