CQC report explained · a residential care home
What the CQC found at Mona Cliffe Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing levels were adequate, but recruitment checks and some medicines records were not always complete.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was carried forward into the overall rating.
- Well-led?
- Requires improvement
- The manager had improved governance, but provider oversight was not consistent. The home also needed better GDPR arrangements, feedback surveys and systems for learning from events.
What inspectors found, May 2022
Rated Good overall; inspectors found people safe and cared for, but the home's leadership and monitoring still needed improvement.
This was an unannounced focused inspection carried out from 13 to 21 April 2022. One inspector visited the home, spoke with people, a relative, staff and a healthcare professional, and checked care, medicines, recruitment and management records.
The home was rated Good for Safe. People felt safe, risk assessments were in place, staffing levels were adequate and infection control arrangements were suitable. Some medicines and infection control records needed updating, and recruitment checks were not always completed before staff started.
The home was rated Requires Improvement for Well-led. The manager had improved some systems, but provider oversight, the GDPR policy, feedback surveys and learning from incidents were not yet consistent. The overall rating improved from Requires Improvement at the previous inspection to Good because the home was no longer in breach of the regulations checked.
People felt safe
Safeguarding systems and risk assessments were in place. People told inspectors they felt safe.
“People were safeguarded from abuse, appropriate risk assessments were in place and people told us they felt safe.” from the report
Adequate staffing
Inspectors found enough staff on duty and the home did not need agency workers. Staff had completed moving and handling training and competency checks.
“We reviewed a sample of staffing rotas and enough staff were deployed to keep people safe.” from the report
Infection control
The home was clean and had suitable supplies and training for infection prevention. Visiting arrangements followed government guidance at the time.
“The home had good stocks of appropriate PPE and staff and people were regularly being tested.” from the report
Recruitment checks
needs fixingSome required recruitment records and checks had not been completed before staff started work. The provider was asked to review its recruitment process.
“The service had not retained and ensured completion of all necessary records and checks before some staffs' employment had started.” from the report
Medicines records
needs fixingSome medicines were not dated when opened, and allergy information was missing from some administration records. The records were updated during or after the inspection.
“Some oral medication was not dated when opened, which meant staff were not always aware if they were following manufacturers guidelines” from the report
Provider oversight
needs fixingThe provider had not carried out recent audits at the home during the COVID-19 pandemic. Inspectors asked for the previous level of oversight to be restored.
“We recommend the provider reinstates the previous level of oversight and quality assurance systems and processes.” from the report
Limited feedback and learning
needs fixingThere were limited examples of lessons learned, and no surveys had been carried out for people using the service or staff.
“The home had not conducted any surveys for people that use the service or staff.” from the report
GDPR policy
minorThe policy for handling personal information needed further updating to cover all necessary areas.
“We recommend the provider reviews their GDPR policy to ensure it is in line with best practice guidance.” from the report
- 01Have all recruitment checks and records been completed before each staff member starts work?
- 02How do you check that medicines are dated correctly and that allergy information is recorded on administration charts?
- 03How often does the provider now visit the home and review its audits and quality monitoring?
- 04How do you collect feedback from residents, relatives and staff, and what changes have resulted?
- 05What updates have been made to the GDPR policy and how is personal information protected?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 20 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, September 2019
Rated Requires Improvement; inspectors found kind, personalised care but weaknesses in risk management and oversight.
Inspectors visited on five days in May and June 2019. The first three days focused on safety and leadership. Two further days looked at all five areas of care. They spoke with people, relatives, staff and health professionals, and reviewed care plans, medicines records and other documents.
People said they felt safe and described staff as kind and caring. Inspectors found enough staff, safe recruitment, suitable medicines management, good support with food and drink, and care that respected people's dignity and choices. Effective, caring and responsive care were rated Good.
The home did not always manage risks properly. Fire safety and legionella risk assessments were not complete, cleaning products were accessible, and confidential records were not always kept securely. Quality checks did not identify all these problems. Safe and well-led were rated Requires Improvement.
The overall rating fell from Good at the previous inspection. The provider was asked for an action plan and CQC said it would monitor progress and return under its re-inspection programme.
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff treating people with kindness, dignity and respect.
“The carers are kind and caring. I have a good relationship with them. I trust the carers and the staff.” from the report
Personalised support
Care plans included people's needs, preferences, life histories and interests. Staff supported people to remain as independent as possible.
“People's care plans contained person-centred information about their life story and included details regarding their childhood, employment, school years, hobbies and interests” from the report
Food and drink support
People's dietary needs were met, including modified diets. Staff provided help at mealtimes and encouraged people to drink.
“There was a calm and unrushed atmosphere, people took as much time as they liked to eat their meal and staff were available” from the report
Safe medicines and staffing
Medicines records were accurate and medicines were stored securely. Inspectors found enough staff and appropriate recruitment checks.
“Staff were recruited safely, and we found all relevant checks had been carried out prior to them commencing their employment.” from the report
Incomplete safety assessments
seriousA competent fire risk assessment had not been completed, despite a request from the fire service. A legionella risk assessment was also missing at the time of inspection.
“Risks to people's health and safety were not always well managed.” from the report
Accessible hazardous products
seriousCleaning products were not securely stored and could have been accessed by people living with dementia.
“Cleaning products were not stored securely around the home and were accessible in sluice room (used for storage).” from the report
Weak governance and record security
needs fixingQuality checks did not identify all the risks found by inspectors. Care plans were kept in an unlocked office that was not always supervised, and a serious injury notification had not been sent to CQC.
“Confidential information was not always stored securely and we saw people's care plans were stored in the main office which was not locked and was not always supervised.” from the report
Moving and handling checks
needs fixingStaff had not completed moving and handling competency assessments, and inspectors observed some poor practice when people were helped to move.
“Moving and handling competency assessments had not been undertaken and we also observed some poor practices from staff when assisting people to mobilise.” from the report
Best-interest records
minorBest-interest decisions were recorded, but the records were not always clear when families were involved.
“However, best interest decisions were not always clear when families were involved in decisions.” from the report
- 01Has a competent fire safety risk assessment now been completed, and can you explain what actions followed it?
- 02Has the legionella risk assessment been completed, and how are the home's hot and cold water systems now checked?
- 03How are cleaning products and other hazardous items kept inaccessible to residents?
- 04How do you check staff are competent in moving and handling, and when was each staff member last assessed?
- 05How are care records kept secure, and how do you make sure serious incidents are reported to CQC on time?
The first three inspection days were focused on Safe and Well-led, while two later days expanded the inspection to all five domains; the previous ratings were Good in November 2017. This explanation was written from the published report of 7 September 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Mona Cliffe Care Home
4 rated inspections over 7 years: the service has held its Good rating throughout.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 13 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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