We carried out a review of the data available to us about Montfort Manor on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Montfort Manor, you can give feedback on this service.
Montfort Manor is a residential care home providing personal and nursing care to 47 people aged 65 and over at the time of the inspection.
Montfort Manor accommodates up to 68 people across three separate floors, each of which has separate facilities. One of the floors specialises in providing care to people living with dementia and another with nursing needs.
People’s experience of using this service and what we found
People did not always receive person-centred activities meaningful to them as information about peoples likes and interests had not always been used to plan activities for them. Despite the service’s excellent outdoor facilities, we observed people living with dementia did not have a walk in the garden or go outside all day. We made a recommendation for the provider to review their management of activities for people, in particular for people living with dementia.
People’s communication needs were known but there was potential improvement to use more alternative methods of communication such as the use of pictures. We made a recommendation the provider reviews their use of alternative communication methods for people, especially for people living with dementia.
People were protected from abuse and avoidable harm. People and their loved ones we spoke with told us they felt safe and staff were knowledgeable in their duties to keep people safe. Risks to people and from the environment were fully assessed and managed to support people to stay safe. Accidents and incidents were reviewed to understand lessons learnt and prevent reoccurrences.
There were enough safely recruited staff deployed to keep people safe and meet their needs.
People were supported to take all their medicines safely and told us they were happy with the care they received for their medicines. We were assured that the provider was managing infection prevention and control effectively.
People’s care needs were fully assessed and included their preferences to ensure their needs were met and clear outcomes planned. Staff were well supported to ensure they had the knowledge, skills and competence to fulfil their roles.
Mealtimes were a positive experience for people, people’s choices were promoted, and people were supported to remain safe from risks around eating and drinking. People’s healthcare needs were monitored and met. Staff worked with other healthcare professionals when required to achieve this.
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.
People were treated with respect by staff who were kind, caring and attentive in their interactions with people. People were supported to make choices about their care and day to day living. People’s loved ones told us they were kept informed and involved in their care.
People's rights to privacy and confidentiality were respected and people’s dignity was maintained.
People were supported to maintain their independence where possible and their care plans informed staff what they could do for themselves and when they needed support.
Peoples care records contained person centred information to ensure people’s care was relevant and meaningful to them. All people and their loved ones knew how to raise a complaint if they needed to. All people and their relatives we spoke with were very positive about Montford Manor and no-one had any complaints.
People’s wishes around their end of life care were recorded and where people were on end of life care, medicines were available to ensure they could remain pain free.
There was no registered manager in post at the time of inspection. However, there were robust interim arrangements with a manager in place who knew the service well. The manager had created a positive, person centred culture in the service. All staff, people and relatives were positive about the manager.
The manager had ensured high quality and safe care for people. Care records were detailed and up to date. Risk management systems were robust. Quality assurance audits and reports were used to check people’s safety and quality of care. Staff worked well together, and there were regular staff meetings to ensure good communication.
The provider and manager proactively sought to identify and promote improvements in the service. Quality assurance systems such as audits and surveys were completed alongside other feedback and events, such as incidents to ensure continuous improvement. The manager monitored their progress with any action plans for improvements to ensure these were completed.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
This service was registered with us on 17/10/2019 and this is the first inspection.
Why we inspected
This was a planned inspection following a new registration.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
We found the following examples of good practice
Visitors were required to complete a Covid-19 screening tool, put on a face mask and use hand sanitiser.
The provider had installed an automatic wall mounted temperature checking device and monitor. This automatically alerted staff if a visitor had a high temperature. Visitors with a high temperature were denied entry to the home.
The assistant manager used a UV lightbox which identified areas of the hands which might have been missed when washed. This was used for staff training and periodic checks to promote good hand hygiene.
A team leader was an Infection Prevention and Control (IPC) Champion. Their role was to train staff in good IPC practice.
The registered manager told us that they were block booking agency nurses, so they only worked in one care setting, minimising the risk of infection transmission.
Uniforms were laundered on-site and not allowed off-site. The registered manager told us that this would reduce the likelihood of infection being brought into the home.