Archived: The Mount Residential Home

The Mount is a residential care home providing personal and nursing care to 17 men. There were younger people and people aged over 65 with mental health care and support needs. Some people were living with dementia. The service can support up to 22 people and accommodation is provided over two floors.

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

The quality of care provided at The Mount Care Home was poor. People were not being protected from risks of abuse and harm, due to the poor condition and cleanliness of the care environment and a lack of risk management and oversight in place by the provider. People were not supported to lead meaningful lives or be part of their local community. People’s privacy and dignity was not being protected, and people were not receiving individualised, person-centred care.

Staff did not have the required skills, training, and knowledge to support people living with complex mental and physical health care and support needs. This resulted in poor monitoring and a lack of risk assessments in place, including for those people assessed to be at risk of choking, falls and requiring support with their medicines.

There were a number of health and safety concerns identified, including in relation to smoking and fire risks, water safety and ligature risks. The lack of provider level audits in place, did not ensure people were being kept safe, as risks were either not recognised or not being addressed. Staff were not following the provider’s own policies, and the lack of supervision and oversight of staff performance by the registered provider did not ensure shortfalls were being addressed, resulting in people being exposed to harm.

People were not 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.

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

Rating at last inspection and update The last rating for this service was good. (Published 12 July 2019).

Why we inspected

The inspection was prompted in part due to concerns received following a recent quality monitoring visit completed by the local authority quality assurance team, which identified a number of concerns relating to safe care and treatment at the service. A decision was made for us to inspect and examine those risks.

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.

You can see what action we have asked the provider to take at the end of this full report.

We have found evidence during this inspection that people were at risk of harm, the provider needs to make improvements. Please see all sections of this full report for further details.

Enforcement and Recommendations

We have identified breaches in relation to protecting people’s privacy and dignity, providing person-centred care and support, safe care and treatment including infection, prevention and control and medicines management, safeguarding people from risk of harm and abuse, safe support with eating and drinking, good governance and oversight of the service, sufficient numbers of suitably trained staff to meet people’s assessed needs and risks, safe recruitment processes, at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore placed in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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

There has not always been strong management and oversight which has meant the service has not always been compliant with legislation. At the last inspection the service was rated requires improvement and the one before inadequate. At this inspection we saw a marked improvement and a rating of good has awarded.

The service had a new manager who was registered with the Care Quality Commission at the end of last year. They were clearly focussed on what they needed to do to ensure people received good outcomes of care and had worked hard to achieve it.

The service provided good outcomes for people which could be improved further to enhance people’s experiences. The registered manager took some immediate actions based on our feedback. We have made two recommendations about the provision of activities, and the training needs of staff.

Staff received the training and support necessary to help them carry out the regulated activity and there were enough staff to ensure people had timely support. People were observed throughout the day and were comfortable and there were no odours in the service.

Staff engagement was positive and people were asked daily what they would like to do and activities were planned accordingly. We however noted some people were not able to participate in social activity unless they were given sufficient support by staff who could anticipate their needs. Some people would not initiate what activities they would like to do and this had an impact on some peoples experiences. Most people were retired and did not routinely go out but sat doing activities in the house such as watching television, colouring and reading. We have recommended that activities are provided in line with people's assessed needs and on a more regular basis.

There was a calm atmosphere throughout the day and the environment suited people’s needs well. Some cosmetic improvements would improve the home environment.

People were supported to stay safe because the environment was well maintained, and risks were identified and where reasonably possible controlled. We have recommended improvements in how the staff document peoples needs in relation to challenging behaviours to help ensure a consistent staff approach.

People had the equipment they needed, and equipment was serviced to ensure it remained safe and appropriate to use. Staff were trained in health and safety, manual handling and infection control to help them ensure people’s safety.

People received their medicines according to prescriber’s instruction by trained staff who had been assessed as competent. Staff monitored people’s health and helped them access health care services as they needed them.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 30 May 2018) and there was one breach of regulation, Regulation 17: Good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Mount on our website at www.cqc.org.uk.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the overall service with particular emphasis on key questions relating to Safe and Well Led and how they were going to meet the regulatory breaches and conditions on their registration. One of which was to have a registered manager in post. Their action plan was submitted to us in a timely way, and updated at regular intervals. We noted over the last three years this service has not achieved an overall good rating. Because the service was rated inadequate, we placed it in special measures. Services in special measure will be kept under review and if we have not taken immediate action to propose to cancel the provider's registration of the service, we undertake to inspect within six months of the last inspection. The expectation is that the provider should have made significant improvement within this period.

At our inspection on the 5 March 2018, we did not identify any new risks or significant concerns. We saw some improvements and were confident going forward that the service would continue to improve. The provider had taken enough action to improve the service and come out of special measures. We identified areas where continued improvements were still required in the way this service operated.

At our last inspection, there was no registered manager in post. At our most recent inspection in March 2018, there was an acting manager in post but they were not registered with CQC. They told us they had submitted an application. The service also had a deputy manager who was on leave at the time of our inspection but came in briefly during our inspection. The registered provider made themselves available during the inspection and told us they were regularly at the service, at least every week. The provider had employed a person to oversee the quality of the service and help bring about the necessary improvements.

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

The duties and responsibilities were shared between the manager, the deputy manager and the provider The service was not able to provide us with all the information we requested so we gave them five days to produce the information. This was received as requested.

The Mount Residential Home is a ‘care home’, people in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The Mount residential home provides accommodation and support to a maximum of 22 men who have mental health needs and/or dementia. At the time of our inspection there were15 people using the service.

At our latest inspection on the 5 March 2018, we found things were improving in terms of staff confidence and morale. People using the service experienced mostly positive outcomes of care. The provider had prioritised up skilling their staff to help ensure they had the knowledge and the key competencies for their role. Staff were caring and attentive to people’s needs and people received timely support.

There were quality assurance systems in place and the provider was working towards their action plan to bring about positive changes and using audits to identify what changes were still needed. However, we found some of the audits were not completed when scheduled and did not always take into sufficient account people’s experiences. There was a lack of clear oversight of the whole service and roles and responsibilities although defined were not overseen by one person, ( i.e. the manager)

There were enough staff to deliver safe, effective care but people were left un-stimulated and unable to go out as they wished when they needed staff support to do this. The provision of activity hours was insufficient and people reported feeling bored and unmotivated.

Risks were mostly well managed but records did not always give sufficient detail particularly in relation to the effective management of incidents to see if they were well managed or could have been avoided.

Staff had a good understanding of safeguarding and how to keep people safe. An open culture had been developed where staff were not afraid to speak out and were confident that actions would be taken.

People received their medicines as intended by staff that were qualified to administer it. Audits helped ensure medicines were given as intended.

Staff recruitment processes were sufficiently robust but new staff were not adequately monitored during their probationary period.

Staff were supported to develop their skills and competencies through a regular programme of training and support. Induction of new staff was improving.

The Commission is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. We found people’s rights were being upheld and staff supported people in lawfully and in line with legislation around mental capacity and deprivation of liberties.

People were supported to eat and drink in sufficient quantities for their needs and any concern about this was monitored to help ensure risks were managed.

Peoples’ health care needs were monitored and staff accessed services for people as required including ensuring appropriate end of life care.

Staff demonstrated good interpersonal skills and communicated with people effectively. They adopted a calm approach with people and exercised tolerance and understanding. People’s independence was facilitated and staff respected their dignity.

Feedback from people was asked but this needs to be developed further.

Care plans were sufficiently detailed to help staff know what people’s needs were but daily notes and incident records need to be in more depth.

Activities were planned for people but these were insufficient and did not reflect people’s individual needs and interests. There was also insufficient engagement with the local community.

The service had an adequate complaints procedure and gave people opportunity to raise concerns/suggestions about the service.

The premises were being refurbished and were suitable for purpose.

We had previously inspected the service in August 2016 and had identified six regulatory breaches. These related to safeguarding people from harm, staffing arrangements, dignity and respect, person-centred care, the governance of the service and the requirement to report incidents to the Commission.

This July 2017 inspection identified seven regulatory breaches, five of which the provider had been in breach of from the August 2016 inspection. These repeat breaches related to safeguarding people from harm, staffing arrangements, person-centred care, the governance of the service and the requirement to report incidents to the Commission. The provider was no longer in breach of the regulation relating to dignity and respect. However, they were also now in breach of regulations regarding safe care and treatment and consent. You can see what action we told the provider to take at the back of the full version of the report.

The Mount Residential Home provides accommodation and support to a maximum of 22 men who have mental health needs and/or dementia. At the time of this July 2017 inspection, there were 19 men living in the home.

There was no registered manager in post. The manager of the home had been in post for approximately eight weeks. They told us that they had commenced the process to apply for registration. 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.

The main partner in the business (referred to as the provider in this report) was at the home most days during the week. They completed most of the care plans. The deputy manager oversaw the management of people’s medicines and was responsible for health and safety checks and related maintenance of the home. The manager oversaw the general day to day operation of the home.

We found that incidents taking place between people living in the home that required reporting to the local authority’s safeguarding team were not always reported. This meant that the local authority was unable to accurately determine whether people living in the home were at risk or would benefit from the input of health professionals. The service had not reported a safeguarding incident to the Commission in over two and a half years.

The provider was not clear about how many staff were required to support people during day. We had previously been told on two occasions that four staff were required. However, staffing levels fell below this, particularly at weekends. Staff training was considerably behind, but some training had been arranged. However, there was little training in place for staff in relation to people’s mental health emotional needs.

Risks to people’s health were not always identified. When they were identified the service did not always take appropriate actions to minimise the risks to people’s welfare.

There was limited understanding and application of the Mental Capacity Act other than at a basic level. Where significant decisions needed to be made assessments had not been carried out appropriately.

People’s care plans did not contain accurate, up to date or clear information for staff to help ensure that they provided a high standard of care and support to people.

The provider’s auditing system was not robust and had not identified the concerns we found during this inspection. The provider had not made significant improvements since the August 2016 inspection.

People received their medicines as prescribed. The staff were kind and considerate and people were comfortable in their company. Most people felt involved in decisions relating to their care. Staff told us that morale was improving in the home. However, the frequent change in managers over the last 12 months had meant that plans to make improvements had not always come to fruition.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Mount provides accommodation and support to a maximum of twenty two men who have a mental health needs and/or dementia. It does not provide nursing care.

There was a manager in post who had been appointed in June 2016. At the time of our inspection, the manager had not submitted an application to the CQC to become a registered manager. 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 this inspection we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

People were not protected from avoidable harm and abuse because staff did not always identify when safeguarding referrals were required. Effective systems were not in place to ensure people were safeguarded and referrals made. Not all risks to people were adequately identified or managed, this included risks relating to the management of the premises.

Staffing levels and deployment of staff was not always sufficient. Staffing levels did not always meet the level that the provider had identified as sufficient to meet the needs of people living in the home.

Medicines were managed safely and people received these in time. People were supported to access health services when required.

Staff did not feel supported to deliver effective care. They felt the quality of training was poor. Healthy eating was not always understood or promoted. There was mixed feedback regarding the quality of the meals provided. The menu offered did not always incorporate people’s individual preferences or needs. The service was not always acting within the requirements of the Mental Capacity Act (MCA).

People were supported by kind and caring staff who knew them well. People and their representatives were involved in decisions about their care. Information was provided to people so they knew how to raise concerns or complaints. People told us they felt comfortable to do so.

Some practices had developed that were not always respectful of people’s privacy and dignity. A closed circuit television camera monitored communal areas. However, there were no records to indicate that people living in the home and others had consented to this and privacy issues had not been considered. People’s personal preferences and needs were not always met; this included the provision of activities.

Staff morale was low in the home. Staff did not feel listened to or supported. There were no effective systems in place to gather the views of staff and people living in the home. Not all records in the home were complete. Auditing and quality monitoring had been ineffective. The provider had not identified the issues found during this inspection.

Is the service caring?

We found the staff and manager offered a service to people living at The Mount that was caring and that the care and support was focussed on the person's individual need. People told us they were happy, well cared for and had no complaints. We received comments such as such as, 'I cannot fault the home at all. I am so well cared for,' .

We looked at records of the individual care provided. These told us the home knew the people who lived there well and gave appropriate care and support when required.

Is the service responsive?

We noted in care plan records that information on any concerns was acted upon and people were supported quickly when issues arose. For example, when a person was struggling with their blood sugar levels or when a person was unwell and required a doctor. We saw the continence advisor who had been asked to visit due to a continence concern and noted the purchase of a new boiler when people could not be kept warm during the cold weather.

Is the service safe?

The home had maintenance records that were checked regularly such as fire records to ensure the building was of a safe standard. The records were audited at random to ensure the building was suitable and safe. Throughout the inspection we noted the clean and tidy environment with no risks or hazards seen during the observations.

Staff had support with training and regular meetings to ensure they could deliver safe care and support to the people living in The Mount. Contact with professionals for further support was triggered quickly when concerns arose.

Records were kept up to date to ensure current care needs were recorded that enabled the correct care to be delivered safely.

Is the service effective?

The people who lived in the home told us that they have been happier since living in The Mount.

We noted in one care plan the use of Age Concern to deliver an advocacy service to one person who had no family support. The home had regular meetings to ensure individual needs were met. One person told us how much better they felt for getting out on their bike more often. This told us that the service was helping the individual people to lead the lives they preferred.

Where a concern was triggered by erratic blood sugar recordings for a person with diabetes the home used effective methods to record and report the findings to health professionals. This showed the action taken was effective and quickly managed.

Is the service well led?

The home had a registered manager who had been working at the home for a number of years. It was evident throughout the inspection that this manager was knowledgeable about each person living in the home. We were informed of the needs and concerns of people in the home in detail. We saw evidence of improvements that had been made since the last inspection and also noted the methods used to audit the quality of the service. We saw completed questionnaires on the service delivered and noted the positive answers given.

Complaints were acted upon thoroughly and people and staff were listened to. We spoke with a social care professional who told us the manager listened and acted on suggestions and that people living in the home were receiving correct care and were safe.

We saw evidence of how staff were supported, such as with training, meetings and one to one supervision by the manager. The senior staff member we spoke with had clear knowledge and understanding of the people living in the home and what the requirements were for each person. We were assured that the service was well led.

We looked at people's care records and made observations of people's experiences of care. We found that care plans were in place and contained some person centred information. However, some records did not accurately reflect people's health and care needs as they were not being reviewed and updated when needed. In addition, mental capacity assessments were not being carried out to determine whether people could or could not consent to their care.

During our visit we looked at some staff files and spoke with the provider about their recruitment processes. We found that recruitment processes ensured that staff did not work in the home unsupervised until they were deemed to be suitable. Staffing levels were low for short periods in the day but no one expressed any concern about not being able to find staff when they needed them.

The care and support needs of people living in The Mount were recorded in their individual plans of care. They were centred round the different needs and had been regularly reviewed to ensure they were up to date and that the support offered met their current needs.

We found that the home was managing infection control appropriately. We found examples and observed staff carrying out tasks that were following correct procedures to reduce or eliminate the possible spread of infections.

We found that the home had enough experienced and skilled staff to support the 22 people living there. The people told us that the support from staff was good. They said, "I get the support I need when I need it. All the staff know us and help us with what we need."

Although the home had not received any complaints there were appropriate methods available for people to complain if they so wished.