Montrose Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

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 provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People received a comprehensive assessment of their needs before moving into the home. These assessments, combined with information from other health and social care professionals, supported the development of care plans that placed the person at the centre of their care. People’s care plans included consideration of their physical and mental health, sensory, social and communication needs. Tools were used to effectively support the assessment of people’s health and care needs, and those were used by staff with the right understanding and skills. For example, people’s weight was monitored and when people were identified as losing weight, action was taken to address this such as a referral to dietitian or fortified diet.

People and most relatives told us they were involved in care planning and reviews. Comments included, “I was always involved in [my loved one’s] care plan. Every resident has their day once a month when you can go into the office and talk about any concerns, come to conclusions. They always answer my questions; we have talked about lots of different things.”

Staff received training in how to support people at the end of life and people living with complex health conditions like diabetes and dementia. Staff applied their learning effectively and in line with best practice, which led to good outcomes for people’s care and support and promoted a good quality of life.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Care and support were planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and best use of technology. Assessments of people’s needs were comprehensive, expected outcomes were identified, regularly reviewed and updated. Staff recognised and responded promptly and adequately to people’s changing needs. Appropriate referrals to external services such as the dietitian or occupational therapist were made in a timely manner, to make sure people’s needs were met.

People's care plans outlined their food and drink preferences. There was guidance in place to support people to eat safely when they were at risk of choking or needed their food to be a certain consistency. Staff demonstrated good understanding of how to support people with this. Systems were in place to monitor people's nutritional intake and weight, and risks associated with dehydration and malnutrition. Care plans identified the level of support people needed from staff to prevent malnutrition and dehydration, and this information was available to the staff working in the kitchen.

At mealtime we observed people who required a modified diet were supported in line with their care plans. Staff were unrushed and patient, meaning people enjoyed their meals at their own pace. For example, some people had their meals prepared to a specific texture, as recommended by a health professional.

People and relatives spoke positively about quality of food and meeting people’s hydration and nutrition needs. Comments included, “They always give [my loved one] enough time to eat, [they] eat very slowly, up to 2 hours. [My loved one] pick food with [their] fingers and like the food. [My loved one] used to get shown plates of food but now [they] are unable to choose but staff know what [they] like. They are doing everything they can in the circumstances. The food always looks pretty and tasty” and “They have a new chef and the food is lovely. They chop [my loved one’s] food up for [them] but [they] can feed [themselves]. They offer lots of options.”

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The provider established effective systems and processes for referring people to external services and to maintain continuity of care. Plans for transition, referral and discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. This meant people’s care was effectively coordinated, to ensure they received timely and consistent support and treatment. For example, the home admitted 5 people from another care home in the neighbourhood after it had been damaged by fire in January last year. Emergency admissions took place swiftly and proactive strategies were implemented to anticipate and reduce distress. Staff supported people and their families during a difficult transition process and helped them to settle down in a new home.

Staff worked well together, and information was shared effectively during handover meetings. Staff worked with other health and social care partners to prevent or reduce the need for admissions to hospital. Health passports and transition plans were stored on the provider’s electronic recording system, reviewed and used consistently. For example, when people needed hospitalisation, they held hospital and communication passports. This meant all relevant staff were able to access the information they needed to understand people’s needs and appropriately assess, plan and deliver their care, treatment and support.

We received mixed feedback from 2 visiting health and care professionals that responded to our request about communication with the home and collaborative working. Comments included, “Requests for information are not always dealt with in a timely matter therefore slowing down assessments” and “There is regular contact with the frailty team, District Nurses and allied health, each resident’s appointments for things such as the optician, dentist, specialist hospital appointments etc are all well organised and attendance facilitated for each individual.”

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People were reviewed by a frailty team during weekly medical rounds when required. This enabled early identification and treatment of emerging illnesses, helping to reduce the need for hospital admissions. Relatives confirmed, “The frailty team visit every Monday. When an ambulance is needed it’s called and comes very quickly. [My loved one] gets appointments very quickly as well.”

We observed people were supported to maintain a healthy and nutritious diet. They had constant access to drinks and fresh fruit and spoke positively about the meals and overall dining experience. One relative told us, “Staff encourage [my loved one] to drink and always tell me if [they] have eaten a good lunch. They will offer support if it’s a bad day and [my loved one] is struggling; staff are very much aware of [their] ups and downs.”

A range of activity sessions encouraged light exercise, and people had access to a secure, accessible garden where they could enjoy fresh air. Staff ensured people had access to appropriate equipment, such as walking aids, which helped them remain mobile and active.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The provider established effective systems and processes to ensure people’s day-to-day health and wellbeing needs were being met, and people experienced positive outcomes related to these needs. Regular reviews of care plans, risk assessments, and clinical observations enabled staff to identify changes promptly and adjust support accordingly. Audits, feedback, and incident analysis were used to drive continuous improvement, ensuring that care remained responsive, evidence‑based, and focused on achieving positive outcomes for people living in the home. We received positive feedback from people and relatives about the support people received to manage their health and wellbeing and enhance independence. Relatives told us, “Staff always make efforts to explain and involve my loved one in decisions about their care provision, though this is now not easy because of my loved one’s memory limitations” and “They do give some residents tasks around the home. For example, 1 resident waters the plants. They like to encourage people’s independence”.

Staff effectively empowered and supported people to be involved in or manage their own health, care and wellbeing needs as much as possible. A member of staff told us, “Staff try and encourage each resident to join in with their own personal care and needs. Seniors and management also have regular conversations with the residents as well as their families to ensure each of our residents have as much person-centred care as possible and involvement as they can.”

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

The provider had established effective systems and processes to ensure people’s human and legal rights were always respected and they had maximum choice and control over their lives. Staff demonstrated good understanding and working knowledge of the key requirements of the Mental Capacity Act (MCA) including Deprivation of Liberty Safeguards (DoLS). People were involved in decisions about their care and treatment as much as possible and staff ensured all practicable steps were taken to help people make their own decisions.

Staff told us they understood the importance of ensuring that people fully understand what they are consenting to and the importance of obtaining consent before they deliver care or treatment. We received positive feedback from people and relatives about staff respecting people’s human rights at Montrose Care Home. One relative commented, “Asking consent is more complex now due to [my loved one’s] memory issues, but seems to happen when appropriate, and efforts are made by staff to explain clearly what’s happening and why.”

People’s mental capacity to make decisions was assessed whenever this was necessary. Where people did not have the capacity to make particular decision, they were given the information they needed in an accessible format of their choice, and where appropriate, their family, friends, legal representatives or advocates were involved. All decisions were taken in people’s best interests ensuring staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.