Mount Hall Care Home

Updated 24 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was undertaken by 2 inspectors and a medicines inspector.

Service and service type

Mount Hall is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Mount Hall is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke to 5 people who use the service and 3 family members to understand their experience of the service. We spoke to 10 staff members including, nurses and health care assistants.

We reviewed numerous care plans and medication records. We also reviewed various records regarding the management and quality of the service.

Updated 24 February 2023

About the service

Mount Hall Care Home is a residential care home providing personal and nursing care for up to 33 people. The service is split over 2 floors. At the time of this inspection there were 28 people living at the home.

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

Governance processes were not always effective in the monitoring of the service. Auditing tools were in place however they had failed to identify some of the concerns we found during this inspection.

There were systems in place to record and analyse incidents however, they were not always effectively investigated. Safeguarding concerns had not always been reported to the local authority. We discussed this with the provider who acted immediately by contacting the local authority Safeguarding team for guidance. A safeguarding policy was in place and staff we spoke to understood their role within the safeguarding process and had received adequate training.

Information in relation to people’s nutrition and hydration was contradictory within records, which placed people at risk, this was discussed with management who responded to this concern during the inspection.

Safe recruitment processes were followed. Staff were trained and spoke positively about the training and support they received.

Systems were in place to enable people to raise both complaints and compliments and these were reviewed by management.

Overall, people who lived at the service and their relatives spoke highly of the support they received.

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 www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 04 March 2020).

Why we inspected

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.

The inspection was prompted in part due to concerns received about medicines and staffing. A decision was made for us to inspect and examine those risks.

We received concerns in relation to the management of medicines and people’s nursing care. As a result, we undertook a focused inspection to review the key questions of Safe, Effective and Well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mount Hall care home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the safe management of identified risks and good governance at this inspection.

We made a recommendation the registered provider reviews how staff are deployed across the service, in line with people’s dependency levels and the layout of the building.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.