Eagles Mount Care Home

Updated 23 March 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Eagles Mount Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Eagles Mount Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection.

During the inspection

We spoke with 17 people who used the service and 15 relatives about their experience of the care provided. We spoke with 25 members of staff including the nominated individual, operations director, facilities assistant, compliance manager, deputy managers, care staff and catering staff.

The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We also spoke to 5 health and social care professional who had experience of the service. We observed care to help us understand the experience of people who could not talk with us. We reviewed a range of records. This included 12 people's care records and multiple medication records. We looked at 3 staff files in relation to recruitment and staff supervision and a variety of records relating to the management of the service.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 23 March 2023

About the service

Eagles Mount is a residential care home providing accommodation for persons who require nursing or personal care to up to 72 people. The service provides support to people who require residential care and people who live with dementia. At the time of our inspection there were 48 people using the service. The building is purpose built and has four floors, people live across three separate floors and can access the ground floor where a working café is located.

People’s experience of using this service and what we found

We observed staff were kind and caring, however, we found widespread shortfalls which had placed people at risk of not having their care needs met and at risk of harm.

The process to report safeguarding concerns to the local authority had not always been followed. This had led to two incidents where external scrutiny had not been possible. Staff had not always assessed people for risks to their health, safety, and well-being, this had placed people at risk of harm. There had not always been enough staff to meet people’s care needs. Some staff had either not completed training or attended refresher training to ensure they were providing the most up to date care and support to people.

Care had not always been planned with people to ensure their care was person centred, not every person had a care plan in place, some people’s needs had not been assessed to ensure their needs were met.

The provider and registered manager’s governance systems had either not been in place or effective enough to identify the shortfalls we found during the inspection, and this had placed people at risk of harm. The registered manager had not always reported reportable incidents to CQC. We have made a recommendation about the provider and registered managers legal requirements.

People did not always receive medicines in a timely manner to ensure infections were treated. We have made a recommendation about the safe administration of medicines. We were somewhat assured the home did all it could to prevent and control infections. We found people had not always been assessed for risks of infection. We have made a recommendation about the infection prevention and control system.

Staff had not always fully assessed people’s needs before they moved into Eagles Mount. We have made a recommendation about the safe admission of people into the service. The design of the building was light and airy; however, it did not always follow best practice guidance for supporting people living with dementia. We have made a recommendation about the adaption and design of the building.

We observed kind and friendly interactions from staff; however, staff did not always speak about people with dignity whilst respecting their equality and diversity. We have made a recommendation about equality and diversity training needs of staff.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support:

People were not always involved in managing risks to themselves and in taking decisions about how to keep safe.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Right Care:

Staff did not always see people as their equal and create a warm and inclusive atmosphere.

Staff had not always received training to ensure people received the right care.

Right Culture:

Staff did not always feel respected, supported, and valued by senior staff to support a positive and improvement-driven culture.

The home had not always been well-led

People told us staff were kind and caring. One compliment from a person said, “I wanted to say a very big thank you to you all for all your help and care you have given me, it is great to be home.” Relative’s comments included, “we are more than satisfied [person] was very poorly when they went in, but they have gained weight and look much better now" “staff are all very nice and very friendly” and, “it’s been very good, the place is more like an apartment block than an old folks’ home, it’s always clean and tidy.”

The registered manager provided us with a reflective statement following the inspection explaining how they felt they had reached the situation we found on our inspection. Eagles Mount had been through some changes in recent months with core staff including senior care staff leaving and new staff starting. The home had transferred onto a new electronic care planning system, this had not been fully updated. People had been admitted into the service without staff fully knowing what their needs were and how people living at the home would be impacted, which had put pressures on the delivery of care. The registered manager had reflected and told us they could have better supported senior care staff into their roles. This led to a lack of oversight and governance. The provider and registered manager acknowledged what had gone wrong and started to make improvements immediately after our inspection to improve the experience of the people living at the service.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 3 August 2022 and this is the first inspection.

The last rating for the service under the previous provider was Requires improvement, published on 8 April 2020.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We have identified breaches in relation to person centred care, seeking consent and working with the principles of the mental capacity act, following local safeguarding procedures, the safe care and treatment of people, good governance of the service, staffing, safe recruitment and making notifications for reportable incidents. Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider and request an action plan 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 continue to monitor information we receive about the service, which will help inform when we next inspect.