6 January 2023
During an inspection looking at part of 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.