You are here

Monson Retirement Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 February 2020

About the service

Monson Retirement Home is a residential care home for up to 50 older people and people living with dementia. At the time of inspection there were 31 people living at the home.

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

Monson Retirement Home had changed owners in May 2019. There had been a Registered Manager who deregistered in October 2019. The new provider had failed to provide enough oversight of the home between June and October 2019. This led to systems to assess, monitor and improve the quality and safety of the home not being implemented or embedded.

Since November 2019 the provider employed an experienced management team who had begun the process of implementing procedures to improve all areas of the home. For this reason, all the planned systems and processes were in their infancy and required completion or embedding into practice.

The provider had an action plan for all the areas they had identified and those we identified at this inspection. Their action plan required time and resources to complete. The provider continued to commit the resources required.

People’s risk assessments and care plans did not always reflect their current needs. The management team were training staff in a new care planning system and had yet to transfer people’s records to this. Staff did not always have information about people’s current needs, which put people at risk of not receiving all the care they needed. The management team put measures in place to inform staff of people’s needs at handover.

The provider was supported staff to improve their skills and knowledge in safeguarding and reported and acted upon concerns.

The provider did not have access to historical records of staff training, supervision or appraisals. This meant they could not be sure what training staff had received. They had implemented a programme of training and supervision which would take time to complete.

The provider did not have all the systems and processes in place to assess, monitor and improve all areas of the home. The management team were setting up a programme of planned audits.

Following an independent external audit in August 2019, the provider was undertaking fire safety and electrical works to comply with fire regulations. These had not been completed at the time of the inspection.

The home required changes to the environment to be suitable for people living with dementia.

There were enough staff deployed to provide people’s care, there were care staff vacancies that were being covered by agency staff. People received their medicines safely. Staff identified when people became unwell and referred them to medical professionals promptly.

Permanent staff knew people well and had formed good relationships. People were regularly engaged in activities they enjoyed and involved people from their local community.

The management team responded to complaints, they followed the provider’s complaints policy. The provider held their first meeting with people using the service and their relatives; they implemented suggested changes and improvements to the home.

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.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 10 June 2017).

Why we inspected

This was a planned inspection based on the previous rating.


We have identified three breaches in relation to risk assessments, safety of the environment, staff training, supervision of staff and management oversight. Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added

Inspection areas


Requires improvement

Updated 11 February 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 11 February 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 11 February 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 11 February 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 11 February 2020

The service was not always well-led.

Details are in our well-led findings below.