Montagu Hall Care 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 people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

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 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. There was a learning culture throughout the service. A root cause analysis approach was used to review accidents and incidents to identify learning and support continuous service improvement.

The provider 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. There was good pre-assessment information gathered prior to people moving into the care home. Information about people’s assessed care needs was shared between services to ensure people’s needs were met safely.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way for this to be achieved. 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 quickly and appropriately. Safeguarding policies and procedures were in place to keep people safe. People told us they felt safe within the service. One person told us, “Oh yes, I feel safe. There are no problems.” Members of staff confirmed they knew how to report concerns. One member of staff told us, “I would report my concerns to the appropriate member of staff, for example a member of the management team. If I had a concern, I believed I couldn’t raise with a member of the management team, I would raise this to the Local Authority or CQC to make sure the situation was dealt with appropriately.”

The management team had a good understanding of the Mental Capacity Act 2005 (MCA).The MCA provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).We found the service was working within the principles of the MCA and, if needed, appropriate legal authorisations were in place to deprive a person of their liberty. Any conditions related to DoLS authorisations were being met.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them. Care plans were detailed and person-centred. Risks associated with people’s care and support were identified and there were clear plans in place to mitigate these risks. For example, 1 person, who was at risk of choking, was supervised whilst eating and their meals were prepared in line with guidance from health professionals. A member of staff told us about how they access care plans and risk assessments in order to provide safe care and support, “We have access to the care plans throughout the full shift. Care plans are updated regularly so I make sure I check the care plans frequently for any changes. Any immediate changes are handed over before shift and members of staff are advised to read care plans before providing care.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service was purpose-built and was spacious and well-maintained. There was a well-organised process to record, monitor and review compliance checks on equipment and systems through the service. This ensured the environment was safe. The provider used an electronic monitored system, which responded to body heat, to monitor people’s mobilisation at night. The system alerted members of staff quickly and enabled them to respond to reduce the risk of people falling. People also had access to a wrist-worn device, similar to a watch, which was the call bell system. Members of staff responded promptly to requests for help triggered using the wrist-worn device. We discussed fire evacuation processes with the registered manager. They reflected on the discussion and implemented changes to further enhance safe evacuation procedures. A full review of each fire exit corridor was completed and additional grab bags were located in these areas so emergency equipment was available at every fire exit point.

The provider 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 which met people’s individual needs. We observed members of staff were deployed effectively and they were available and responded to people in a calm and caring manner. Members of staff were recruited safely and had accessed appropriate training and personal development to enable them to deliver care safely. A relative told us, “There are plenty of staff, if you ring your buzzer somebody appears within 5 to 10 minutes. [Staff] are all very friendly, there is nothing to grumble at staff about.” A member of staff told us, “Staffing levels are generally good and allow us to provide care safely. I receive regular mandatory training, supervision and guidance from my manager. This includes updates in safeguarding, medication, infection control and manual handling. I have regular supervision and annual appraisals. My manager is approachable and supportive, and always willing to provide advice or extra training if needed.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The care home was clean and well maintained. There were no significant issues or shortfalls in relation to infection prevent and control (IPC). Members of staff confirmed they had access personal protective equipment (PPE) and appropriate training to manage the risk of infections. One staff member said, “PPE is kept in different parts of the building on wall storage stations, so it is easy to access when needed. I have IPC training each year and I refresh it annually.”

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. Administration of medicines was managed safely. People were involved in discussions and reviews of risk assessments, so they were able to administer and manage their own medicines. Medicines were stored safely and there were safe systems in place to monitor, review and audit administration processes.