Mountfield

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 remained requires improvement.

This meant some aspects of the service were not always safe and we were not fully assured about safety. There was an increased risk that people could be harmed.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider had a proactive and positive culture of safety based on openness and honesty and investigated and reported safety events, rectifying actions to mitigate future risk were not always fully embedded. For example, where safety incidents had occurred, we saw that whilst appropriate mitigating measures had been implemented, these had not always been consistently applied.

However, the service had an effective system in place to record and analyse safety events and we saw that appropriate and prompt referrals had been made to other stakeholders as required.

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.

People told us the process of moving into the home was supportive, welcoming, and trouble-free. They told us the service took time to answer their questions and prepare them for the move. One relative we spoke with said, “The admission was extremely smooth and supportive. The whole team put significant effort into both allying my fears but also, significantly, making sure [family member] felt welcomed.”

Whilst the provider worked well with healthcare partners and shared concerns quickly and appropriately, relatives did not always feel confident that their family members were fully protected from harm. This was because there had been a number of injuries within the service that remained unexplained and the relatives we spoke with did not feel assured about how these had been managed. However, our findings showed that where unexplained injuries had occurred the service had taken appropriate action including making referrals to health professionals and the local authority safeguarding team.

In addition, the service had not fully assessed people’s capacity to make decisions in all areas required. For example, where people were using assistive technology. In response to our inspection findings, the service promptly ensured these were completed as required.

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

Whilst we found no harm to people, we saw that agreed risk management plans were not consistently followed by staff. People told us this and records confirmed it. For example, for 1 person, the service had assessed that 30 minute observations were required to mitigate the risk of falls. We found these had not been consistently adhered to meaning the person was placed at increased risk. Some staff also raised concerns about this telling us expectations around interactions, such as observations, were often impractical given the breadth of their role and responsibilities.

In response to our inspection findings, the service promptly reviewed the risks to people.

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 had a robust servicing, maintenance, and monitoring system in place to ensure the environment and equipment remained safe for people. This included in relation to fire management, Legionella management, and utilities safety. There was also a business continuity plan in place to ensure people remained safe in the event of an adverse safety event such as loss of utilities or a threat to the environment.

The provider ensured there were enough safely recruited qualified, skilled, and experienced staff to meet people’s needs, and staff had received support, supervision, and development. However, staff did not always work together to provide care that met people’s individual needs. For example, relatives gave us examples of where care was inconsistent and relied upon certain staff members to deliver consistent care as planned. One relative told us, “Communication between caregivers seems to be lacking, which leads to inconsistencies in the care provided.” Another relative told us they had raised a concern about their family member’s care to various staff members over a period, none of whom appeared to know what the issue was despite having raised this several times.

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.

We saw that the home was consistently clean and hygienic throughout and that staff wore personal protective equipment as required. The people who used the service agreed with 1 telling us, “The staff are always washing their hands.” Additional measures were in place to protect people from the risk of infection and these included an infection prevention and control policy and regular audits.

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

For example, whilst people mostly received their medicines as prescribed, we found instances where they were not given at the appropriate time or records failed to record the time the medicine was administered. Furthermore, robust checks were not being completed to ensure medicines patches were being administered effectively and safely. Some medicines that were only administered when required had clear instructions for staff to follow, such as when somebody might need a medicine to treat a seizure; others needed clearer details such as how to manage low blood glucose or pain. In addition, we could not be assured that all medicines incidents had been reported although we found no harm to people as a result. However, staff had received training in medicines management and their competency to administer medicines had been assessed.