Archived: The Mount Residential Home

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 improvements. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of 2 legal regulations. These are in relation to safe care and treatment due to inadequate risk management, and care planning, and consent due to lack of systems being followed.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the home was not always focused on safety and learning from incidents that had occurred. For example, records were not always maintained of incidents that had occurred in the home. This meant these were not analysed consistently for patterns and trends to mitigate future risks to people. Where analysis of incidents had been completed the information was inaccurate when compared with other records in the home and lacked detail of how future risks would be reduced. There was also a lack of evidence to demonstrate outcomes of any learning had been shared with staff. A lack of clear and consistent guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were not always implemented and embedded.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not always listen to concerns about safety and did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the home was not always focused on safety and learning from incidents that had occurred. For example, records were not always maintained of incidents that had occurred in the home. This meant these were not analysed consistently for patterns and trends to mitigate future risks to people. Where analysis of incidents had been completed the information was inaccurate when compared with other records in the home and lacked detail of how future risks would be reduced. There was also a lack of evidence to demonstrate outcomes of any learning had been shared with staff. A lack of clear and consistent guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were not always implemented and embedded.

Relatives told us staff did keep them informed about incidents that may have occurred. A relative told us, “The staff are good at keeping me informed if anything happens, they always ring.” However, due to the lack of consistent records we could not be assured relatives had been informed about all the incidents involving their family member.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Although systems were in place to assess people’s needs prior to their admission we found these were not always used. If information was obtained this was not always detailed. For example, we reviewed the records for the 2 people who had recently moved into the home. We found the provider had not completed their own assessment of people’s needs and had used the Local Authority’s assessment to help assess them. The provider used this information to complete people’s care plans. However, we found for 1 person key information such as allergies to medicines had not been transferred to their care plan to ensure all staff were aware and to ensure continuity of care and safety. Action was taken to address this when we brought this to the manager’s attention.

We sought feedback from partner agencies who told us the provider was not always ‘proactive’ in implementing recommendations they had made to improve the systems in the home to monitor people’s safety and improve the records in place to support people’s continuity of care.

Some relatives we spoke to, told us they been asked to provide some information as part of the admission process. A relative told us, “We were asked a few questions about what daily support [person] needed but that was it really, nothing comprehensive and we haven’t seen an assessment or care plan since [person] moved in.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not 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 provider had failed to ensure they consistently followed safeguarding procedures or responded appropriately to potential abuse. They had failed to protect people from potential harm and report such concerns. For example, we found where people had fallen the circumstances leading to the fall had not always been explored to safeguard people from harm. Where people had repeated falls within a short timeframe or had sustained a serious injury this information had not been shared with the Local Authority as a safeguarding alert as required by their ‘Preventing falls’ procedures. Where needed this then may have also resulted in a notification to be submitted to CQC.

We also found recommendations and learning from a ‘Safeguarding enquiry’ had not been shared with staff or implemented in a timely manner to prevent potential avoidable harm and neglect.

We saw from the training record not all staff had completed safeguarding training and several other staff’s training had expired. Staff we spoke with were able to tell us what action they would take if they had any concerns about people’s care. One staff member told us, “I would report it to the senior in charge if I thought anyone was being abused in any way.” Not all staff knew how to escalate concerns with other organisations. People and their relatives told us they felt safe with the staff supporting them. One person said, “The staff are great here, and I feel safe.” A relative told us, “I have no concerns about [person’s]’ safety I think they are safe, and staff treat them well.”

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

The provider failed to manage risks effectively to ensure people received safe care. The management of risk was of concern during our previous inspection and improvements had not been made at this assessment. We found multiple aspects of the service were unsafe, which placed people’s health and safety at risk. For example, we found 2 people who were at risk of choking were not provided food in accordance with their assessed needs. We found, from the electronic records, multiple people had fallen. Incident records had not always been completed of these falls, or where records had been completed, detailed information was not provided. This meant actions to reduce the risks had not been recorded or shared with staff to mitigate the risk of future falls. In addition, people’s care plans and risk assessments had not always been updated in response to these falls to provide guidance to staff on how they should support people to reduce future risks.

Where people had known health conditions which placed them at risk of harm, staff were not always provided with clear information and guidance on supporting people in relation to these and managing associated risks. Risk assessments lacked clear guidance for staff to follow about how the risk should be managed. For example, where people were at risk of self-harm or neglect.

Some relatives told us risks to people could be managed better. Relatives felt the changes in management impacted on communication and the support people received. We found most staff knew people’s needs and told us they understood how to manage people’s care in a safe way. People were supported by a consistent staff team most of the time.

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 failed to identify and take steps to control potential risks within the home. The provider had failed to take timely action to address requirements from a Fire Officer’s inspection that was undertaken in October 2024. This required the provider to complete essential work to ensure the home would be safe in the event of a fire. The provider was unable to give a reason for the delay. The provider did make arrangements for the required work to be commenced when this was raised during the assessment.

The provider had not ensured risk assessments of potential risks in the environment had been reviewed in accordance with their own guidance. A risk assessment for the stairs that were accessible from the ground floor to the first floor had not been updated since March 2023. The guidance on the risk assessment stated this should be reviewed every 3 months. The provider could not provide any evidence this had been completed. There were several people living in the home who were at risk of falls, and who lived with dementia who had unsupervised access to these stairs. Although we were informed no-one had attempted to use the stairs prior to this assessment, we were informed following our visit a person had used the stairs and climbed to the top. Action was taken in response to this incident to reduce the risks to people.

People and relatives, we spoke with did not raise any concerns in relation to the environment being unsafe.

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

The provider failed to ensure all staff received appropriate training to meet the needs of people and their known health conditions. This included mental and physical health conditions with a long-term impact on people’s care, such as heart failure, complex dementia, specialised dietary needs, and suicidal thoughts. Records provided demonstrated some staff had not received core training for their role for example, practical moving and handling training, safeguarding, and first aid. This meant staff may not have had the knowledge or skills to support people safely. The provider failed to carry out spot checks or competency assessments to observe staff practices in areas such as moving and handling and supporting people with complex dementia. This meant the provider could not be assured staff were safely and effectively meeting people’s needs.

Staff told us and the records confirmed regular supervision was not provided. A staff member said, “Due to the changes in management supervision has been hit and miss. Since the new manager started, I have had one supervision already which is good. If I needed support previously, I would speak to the senior or my colleagues.”

The provider's recruitment systems continued to not be effective. Safe recruitment practices were not always followed. People were at risk of harm from receiving care and support from unsuitable staff. We raised the unsafe recruitment practices following our last assessment and the required improvements had not been made on this assessment. We reviewed the recruitment files for 3 staff that had recently been recruited. The provider had failed to evidence they had explored any gaps in employment records and mitigate any associated risks. Where a current police disclosure and barring check (DBS) had not been obtained a risk assessment had not always been completed. In addition, where staff had been employed with a positive DBS a risk assessment was not available for us to review. This meant we could not review the rationales for these decisions and the safeguards put in place to ensure the staff members were suitable to work with vulnerable people.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found several areas of the home required renewal due to being worn. For example, some carpets in some communal areas and bedrooms were stained and, in some cases, had an unpleasant odour. Paint on some skirting boards, handrails and doors was chipped exposing the bare wood. These areas could not be cleaned effectively which meant people were at increased risk of cross-contamination. The provider had developed a refurbishment plan with timescales for when areas were due to be redecorated or replaced.

People and relatives told us they thought the environment could be improved. A person said, “The walls could do with a lick of paint and updating.” A relative said. “The home is dated and needs modernising but still reflects a homely environment.”

The Local Authority infection control team visited shortly after our assessment, and they made recommendations for the provider to address. This included, to replace worn items and stained flooring.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Although people told us and records showed people received their medicines as prescribed, we found some improvements were needed with the records in place. For example, we found nutritional supplements prescribed for people were not recorded as part of the stock balance for medicines held within the home. This meant we could not be assured people had received these as required. We also found some of the guidance for administering ‘as required’ medicines lacked detail to guide staff about the signs and symptoms they needed to be aware of.

We found medicine records for prescribed creams were not always signed to confirm people had these applied as needed. Where people were prescribed medicines that needed to be administered at specific times the records did not always reflect the actual time people had received these. The manager took action to address these issues when we raised them.