Mount Vernon Terrace

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 improved to good. This meant people were safe and protected from avoidable harm.

The provider was previously in breach of the legal regulation in relation to safe care and treatment. We found significant improvements had been made at this assessment, and the provider was no longer in breach of regulation.

People and those important to them were supported to understand safeguarding and how to raise concerns when they didn’t feel safe. When concerns had been raised, the management team had promptly reported these to the relevant agencies to make sure timely action was taken to safeguard people from further risk.

Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to the management team.

People were being supported to have choice and control and were involved in planning their care. Managers reviewed staffing levels regularly to make sure there were always enough on duty. Staff showed a good understanding of specific areas of people’s care needs.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt improvements would be made to their care if needed. One person said, “If I needed to, I would raise this with the support staff or the management. I have never needed to raise any issues with them.” Another person said, “I am really pleased with my new chair.” We observed staff interactions with this person. Staff were very attentive. Ensuring this person was not only feeling comfortable but engaged in conversation.

Staff had received regular supervision sessions to review what was working well, and to identify areas where their practice and resilience could be improved. We saw actions from these sessions had been followed up to enhance staff skills and learning from incidents. The director had implemented improved debrief documents, to support learning after a significant event. These showed action points for improving care planning, risk assessments, or staff training where required.

Staff received relevant training to meet the range of people’s needs at the service. The competency checks in place to support their continuous learning were improved and effective. There were processes in place for the management team and staff to review incidents. Staff meetings and individual supervision sessions allowed staff to reflect on what was working well, and what could be improved at the service.

There was a provider policy for the duty of candour. This policy guided the service to tell the person (or, where appropriate their advocate) when something had gone wrong. We reviewed complaints that had been made and saw this policy had been followed by the management team.

The management team 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.

People told us the communication between the care home and external health and social care teams had improved; to ensure positive experiences and safe transition from other services. Staff showed a good knowledge of which health and social care professionals supported each person. This ensured people living at Mount Vernon Terrace had been reviewed by external teams when their needs had changed.

Where people required external health and social care support, documentation showed that referrals had been made in a timely manner. For example, where people required input from an occupational therapist for review of walking aids following a fall. Where people required a review from a dietician or speech and language therapist for support with improving their food and nutrition management, this had been actioned.

Daily records contained specific details to enable clear oversight of people’s specific needs. For example, the daily monitoring sheet for people, which included details related to personal hygiene, food and fluid intake had been reviewed and a new recording process was in place. This allowed clear oversight of people’s needs.

Partners told us the service had been open and responsive to the concerns identified at our previous inspection. The service had been involved in an extensive provider investigation procedure with the local authority since this inspection. We found the required improvements identified in this process, were embedded to ensure processes were clear, robust and protected people from the risk of harm.

The management team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns appropriately.

People told us they felt safe from abuse. People told us they felt no unlawful restrictions were imposed upon them. One person said, “I have no issues with my dignity and privacy being respected at all times. I feel the home promotes my independence. If I require support the staff will support me, I am able to access the community without any restrictions in place.”

Safeguarding was now a priority at Mount Vernon Terrace. We found the new manager and director understood their responsibility to ensure timely notifications were submitted to the local authority safeguarding team or the CQC to ensure that incidents could be promptly investigated.

We saw people and staff had positive relationships at Mount Vernon Terrace. There was an open culture of communication, and we saw no evidence that people were at risk or fearful of the staff team.

Staff we spoke with understood how to respond to allegations of abuse. Staff we spoke with felt confident the management team would act appropriately if they raised concerns. Staff were confident in using whistleblowing processes if they felt concerns were not being responded to by the management team.

There was a clear understanding shown by the management team, of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We found the requirements of the MCA were being consistently met and applied to ensure people’s rights were being upheld.

The management team 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.

People told us that they were able to communicate their needs, to receive the right type of support. One person said, “When I have needed to press the call button for support the staff respond very quickly. Sometimes when I have not felt safe, I have pressed the call button and the staff have responded quickly.”

People told us that staff understood their needs well and offered support to keep them safe. One person told us, “I feel the home provides a good quality service. When I had a recent injury, the staff at the home supported me well until I was able to look after myself and be more independent.”

The whole staff team showed empathy and understanding towards people, and everyone appeared happy and relaxed with staff. People’s needs were clearly documented in their risk assessments, so staff had clear guidance on a person’s mental, physical and social needs. People’s communication needs were clearly recorded. This allowed staff to understand people’s needs and wishes and support them to stay safe.

Staff had received relevant training on how to support people’s individual needs. Some people at the service could become distressed due to their mental health diagnoses. Staff had received training on how to support people when they became anxious or distressed. Any distress incidents where people had placed themselves, others and staff at risk of potential harm had been reviewed and any learning from these was being applied to improve care outcomes.

There were updated, individualised, processes in place for how to respond in an emergency. Each person had a concise, individual Personal Emergency Evacuation Procedure in place (PEEP), which was reflective of their needs.

We saw from supervision records that staff had a good knowledge of the PEEP records for people.

The directors had a robust environmental improvement plan in place, to ensure the lived environment was a safe, pleasant environment for everyone. We saw people’s bedrooms had been personalised to their own tastes and included any equipment or adaptations to support their needs. One person said, “There have been many changes. The home is being redecorated and there is also new furniture. There have been staff changes, but this has been for the better. “

The management team had processes in place for monitoring the safety of the environment. For example, they documented their regular checks around the building. We saw that areas which had been identified, were included in an overall service improvement plan, to ensure people were kept safe.

The management team had been served with an enforcement notice by Nottinghamshire Fire Rescue Service on 18 October 2024. We saw significant progress had been made to achieve compliance with this.

We saw from records that people and the staff team had taken part in regular fire drills. Wayfinding signage, lighting on the communal corridors and improvement work to internal fire retaining doors was nearing completion, with a contractor present on the day of our assessment.

People and the staff team felt confident that the building was well maintained and was being refurbished to a high standard to ensure people were kept safe from the risk of harm.

The home was safe in the event of a fire. Corridors and flooring were well maintained and kept clear of any blockages, this meant people and staff could easily follow fire evacuation escape routes. Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain where people would be supported to move to as the designated safe space.

Areas of the premises which had previously placed people at risk of injury, had been addressed by the directors. Furniture was now secured to walls as required, bedroom furniture was replaced, and the toilet basins, cisterns and sinks in bathrooms were well maintained.

Windows were unable to be opened wide. This safety feature should prevent people from falling or climbing out and is in line with guidance from the Health and Safety Executive (HSE).

The environment was kept safe, by effective maintenance and refurbishment. There had been regular checks to ensure the water quality was maintained and temperature checked to reduce the risk of water-borne bacteria (like legionella.) The gas heating system was regularly serviced to prevent harm to people.

The management team made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People and their visitors told us there were enough staff, and their needs were responded to. One person said, “I feel there are enough staff across all shifts and feel they are trained well I have no concerns with any off the staff at the home.”

Staff we spoke with explained how the service provided sufficient training for them to ensure they were skilled and knowledgeable in their roles. A staff member we spoke with told us they had been fully supported to progress with completing a higher level NVQ.

Staff told us they had regular opportunities to meet their line manager on a one to one basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance/training if needed.

Staff we spoke with felt there were sufficient staff to support people with their identified needs. We saw the management team and staff were suitably trained to complete their roles. We saw that staff used their understanding of people as individuals, to respond to people’s needs. One person we spoke with gave positive feedback about of the knowledge of the staff team, saying, “I feel the staff are well trained and have confidence with the way they prompt me if needed. The staff make me feel safe due to my mental health, and me not feeling safe when they are not around.” Another person said, “I feel the staff are well trained in their roles.”

We saw there were processes in place to assess staff competency. Where we had previously raised concerns with the director around the competency assessments completed for medicines administration, we found the processes in place were now robust. For example, these allowed understanding of specific medicines and their potential impact on people’s wellbeing.

If staff did not provide the expected level of care, there were processes in place to monitor and improve their performance.

The management team assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People told us that the home environment was improved and was kept clean. One person said, “It is great now, much better for us.”

Good infection, prevention and control practice was now a priority at Mount Vernon Terrace. The service was clean and hygienic. Due to the ongoing refurbishment, the service was now able to be effectively deep cleaned to ensure people were protected from the risk of infection.

We saw the kitchen was managed in a hygienic way by a knowledgeable member of staff, to ensure people were not at risk of food borne infections. The most recent check from the food standards agency, had rated the service 4 stars in October 2023. Staff had received food hygiene training; they were able to explain what actions they took to reduce the risk of food borne infections. A member of staff who was responsible for meal preparation told us, “We have a 5-star food hygiene rating. We work very hard to maintain that.”

There were robust processes and policies in place, to ensure the environment was kept clean and hygienic. The management team had implemented daily walk around records. These highlighted any shortfalls and enabled them to take a robust approach to rectifying these.

If an infection outbreak occurred (for example diarrhoea and vomiting), there were clear processes in place to reduce the risk of this spreading to other people at the service. For example, there was regular high touchpoint cleaning, which reduces the spread of infection on areas which are used the most by people, such as communal toilets, handrails on stairs and handles on doors.

People were encouraged and supported to maintain their own personal cleanliness. Where people had been identified as being resistant to support with personal care, there was detailed exploration by the management team to engage positively with people to encourage them to self-manage their daily personal care.

Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

The management team made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us that they were happy with the support from staff with their medicines. One person said, “The staff support me with taking my medication three times a day. I have never had a problem with anything.” Another person said, “I am feeling well with my medication at the moment. The staff support me with this 3 times per day with tablets and once a month with an injection.”

Staff were able to explain how they supported people to take their medicines safely. Staff understood who to report medicine concerns or errors to. For example, if they felt a person’s medicine was no longer effective, there was documentation to support this. Information showing which health professionals had been involved in these decisions was being transferred into a person’s care plan or medicines risk assessment.

Some people at the service were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw staff had followed national legal requirements by storing these medicines in an extra secure place. The documentation for these medicines was in place and regular audits were completed by the management team.

Where medicines needed to be stored at a certain temperature, this had been done. For example, some people required their medicines to be stored in a fridge. Staff had checked the fridge temperature on a daily basis to ensure it was working as expected.

We found improved documentation was in place for people requiring ‘as needed’ medicines. Where people were prescribed medicines like paracetamol or co-codamol for occasional pain relief, we found the variable doses had been accurately recorded on their medicines administration records.

Medicines administration records we reviewed for people showed clear records where staff had given prescribed medicines for people. Any errors and gaps were being promptly identified in medicines audits completed by the management team.

People’s medicines care plans had been read and signed by all staff, to acknowledge they understood the person’s medicines regime and the potential impact of these on their wellbeing. Staff had received training on how to administer medicines safely. The management team had recorded regular assessments of staff’s competency, to ensure they were following best practice. One staff member told us, “I am confident with the new medicines systems in place.”

Staff completed regular checks of the amount of medicine in stock. The medicine’s reconciliation records, and the returns book were accurately recorded. This meant the service could be assured that suitable stock levels were always in place at the service to ensure people received their medicines as prescribed.