Moundsley House

Updated 27 April 2022

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 three inspectors, a specialist professional advisor 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. The specialist professional advisor worked had expertise as a nurse and in working with people living with dementia.

Service and service type

Moundsley House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from professionals who work with the service. We used the information the provider sent us in the provider information return. This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all of this information to plan our inspection.

During the inspection

We spoke with nine people who used the service and four relatives about their experience of the care provided. We spoke with nine members of staff including the registered managers, nurses, care workers administration staff and the chef. We reviewed a range of records. This included three people's care records and 15 medication records. We looked at three staff files in relation to recruitment and staff support. A variety of records relating to the management of the service, including policies and procedures were reviewed. We completed some general observations and 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.

After the inspection

We continued to seek clarification from the provider to validate evidence found and reviewed additional evidence relating to improvements made by the provider to the concerns raised about the environment.

Updated 27 April 2022

About the service

Moundsley House is a residential care home providing personal and nursing care to up to 60 people. The service provides support to adults living with dementia. At the time of our inspection there were 47 people using the service. Moundsley House is part of a purpose-built care village which currently has two other homes open and two which are dormant on the site.

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

People’s risk and needs were assessed and managed well by staff. Issues with the environment in some areas were resolved promptly and there had been no impact on the safety of people from this.

The registered managers had oversight of the home and had quality assurance systems in place however development of these would give greater oversight and support to the managers in identifying some of the issues CQC found relating to the environment.

Care plans were in place and reviewed regularly but would benefit from being more detailed to support new and agency staff to have a better understanding of the care they needed to provide.

Medicines and IPC were managed well. Staff received training and support to ensure medicines were managed safely.

Staff sought people’s consent before providing support. 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.

Staff, people and relatives were positive about the registered manager and the support they provided.

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

Rating at last inspection:

The last rating for this service was good (published 06 November 2020).

Why we inspected

We received concerns in relation to staffing levels, staff training and medicines management. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has not changed following this inspection.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe, effective and well-led sections of this full report.

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

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. This included checking the provider was meeting COVID-19 vaccination requirements

Follow up

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