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 people’s safe care and treatment and recruitment processes.

This service scored 56 (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.

At our previous assessment we found information from incidents and accidents was not being used to drive improvement. At this assessment some improvements had been made. Information about incidents was gathered and analysed. However, staff did not receive debriefs following incidents. These can be an opportunity for staff to reflect on what went wrong and what action could be taken to mitigate future risk. There were no records of lessons learned and no evidence this was discussed at staff meetings.

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.

There were processes to help ensure, when people moved between services, key information was shared to help sustain continuity of care. For example, hospital passports had been developed to provide information for hospital staff in the event of an unplanned admission.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They 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 always share concerns quickly and appropriately.

The service was not consistently following the Mental Capacity Act 2005 (MCA) code of conduct. The MCA sets out how to assess and make decisions on behalf of people who lack capacity to make decisions for themselves. At our previous assessment we found mental capacity assessments were not always completed as required. No improvements had been made in this area. Capacity assessments had not been completed for 1 person although a Deprivation of Liberty Safeguards (DoLS) authorisation had been applied for and granted.
Since our last assessment, processes to protect people from the risk of financial abuse had been improved. There were systems to document when the service was holding any personal monies for people.
People and relatives told us they had no concerns about personal safety. One person commented, “Oh yes, I am safe. Everything is very good here.” A relative described how worried they had been about their family member after they had fallen several times. They told us they were now reassured the person was safe and well cared for.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments had been completed. There was guidance for staff on how they could keep people safe when risks were identified. This included risks associated with people’s actions when they were distressed. Staff were able to explain to us how they supported people at these times.
Staff supported people to understand and manage risk. For example, we observed 1 person using the stairs with difficulty. A member of staff gently reminded them they should use the stair lift. They told them, “I know you can do it, but it would be safer if you used the stair lift.”

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.

Records dated 1 May 2026 showed emergency lighting was not working in the hall, main entrance and office and staff would have to ‘resort to torches’ in the event of an emergency. At the time of our assessment the emergency lighting was still not working.
Some rooms required window restrictors to be fitted. This had been identified and action was being taken to complete the work.
Since our previous assessment a maintenance worker had been employed. Staff recorded any defects in a maintenance book and these were signed off when completed. Staff told us defects were normally quickly addressed.
Safety checks were completed by external companies. For example, fire extinguishers, hoists and a stair lift were regularly serviced. There was certification to evidence the water system had been checked for legionella. A fire risk assessment had been completed and there had been no high priority actions identified which needed to be completed.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Following our previous assessment staff files had been audited and action taken to follow up on any missing references. However, we continued to have concerns relating to safe recruitment. One member of staff had no criminal record check on file and had not completed any safeguarding training. Their name was not included on the list of staff files audited and so this gap in their records had been overlooked. A relative of the provider sometimes helped out in the service, administering medicines when there was no member of staff available with the relevant skills and knowledge. There was no staff file for this person or any record they were competent to administer medicines. Following our assessment visit the provider took action to address these concerns.
Some staff had not had a supervision in 2026 and did not have one planned. These meetings can provide an opportunity to raise any concerns or highlight gaps in training. Despite the lack of formal supervision, staff told us they were well supported and could approach a manager for support and one to one advice at any time.
A dependency tool was used to assess how many staff were needed to meet people’s needs. This had not been updated since 29 April 2026. Since that time there had been changes in occupancy. However, on the day of the assessment visit there were enough staff to meet people’s needs. Call bells were responded to quickly and we saw staff took time to make sure people were comfortable and had everything they needed. One person spent most of their time in their room. They told us staff regularly checked on them.
Staff training was regularly refreshed and now included training relating to supporting people with a learning disability and autistic people. However, 1 person had a catheter fitted. Staff had not completed training on catheter management.

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.

Apart from the medication room the service was clean and tidy. Cleaning schedules showed deep cleans of communal areas were completed regularly. Relatives told us they had no concerns about the cleanliness of the home. Comments included, “It’s really, really clean. I’ve never found it dirty” and “[Relative’s] room is always clean and tidy.”

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 in a locked room. The carpet was dirty and did not support a sterile environment. Medicines should be stored at temperatures no higher than 25 degrees to ensure they remain safe and effective. Records showed between 8 June and 22 July the temperature of the room had regularly exceeded this. On 3 occasions the temperature had exceeded 30 degrees, but action had not been taken to reduce the temperature of the room.
Following the assessment the provider sent evidence the carpet in the medicines room had been replaced with vinyl flooring and an air conditioner unit fitted.

Some medication was stored in a fridge; this medicine was marked as being required to be stored at temperatures between 2 – 8 degrees. Staff told us they had stopped checking the temperature of the fridge on 6 July 2026.
Protocols for medicines to be taken when needed did not always effectively guide staff on when and why this medicine should be offered.
Records showed people received their medicines as prescribed.