CQC report explained · a residential care home
What the CQC found at Monson Retirement Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not consistently stored, administered or managed safely. Staffing levels, falls procedures and some infection control practices also needed improvement.
- Effective?
- Requires improvement
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Requires improvement
- This area was not inspected during this focused visit. Its previous rating was carried forward, although feedback about staff was generally positive.
- Responsive?
- Requires improvement
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- There was no registered manager, and leadership changes had unsettled relatives. Systems and staff responsibilities needed to become more consistent and fully established.
What inspectors found, November 2021
Monson Retirement Home was rated Requires Improvement; inspectors found unsafe medicines management and weaknesses in staffing oversight and leadership.
This was an unannounced focused inspection on 2 November 2021. Two inspectors visited the home, an expert by experience spoke with relatives, and the inspection team reviewed care records, medicines records, staff files, audits and other documents.
The main safety problem was medicines. Some medicines were left where people could reach them, a medicines trolley was unlocked and unattended, and records showed missed checks and gaps in administration records. This created a potential risk of harm and was a legal breach.
Staff recruitment difficulties and agency use affected staffing. The home had no registered manager at the time, although a new manager and deputy had been recruited. Inspectors also found that some systems, staff responsibilities and procedures were not being followed consistently.
The overall rating changed from Good at the previous inspection to Requires Improvement. The inspection only assessed Safe and Well-led. The other three areas were not inspected and their previous ratings were carried forward.
Safe recruitment and training
The home carried out recruitment checks and provided continuing training and supervision for staff.
“The provider had safe staff recruitment checks and staff received ongoing training and support.” from the report
Monitoring risks and incidents
The management team reviewed incidents for patterns and took action intended to reduce further risks.
“The management team had systems in place to review, monitor and analyse all incidents.” from the report
Partnership working
The home worked with external health and social care professionals, and records showed that recommendations were followed.
“Partnership working was effective in supporting people to achieve positive outcomes.” from the report
Medicines were not managed safely
seriousSome medicines were accessible, the medicines trolley was left unlocked and unattended, and records contained missed checks and other gaps. Inspectors said this put people at increased risk of harm.
“The storage, administration, and management of medicine was not consistently safe.” from the report
Staffing levels were not assured
needs fixingRecruitment difficulties and agency use affected staffing. Inspectors were not satisfied that the minimum staffing levels assessed by the provider were sufficient.
“we were not assured the provider's minimum safe staff levels were sufficient.” from the report
Leadership was unsettled
needs fixingThere was no registered manager during the inspection. Relatives found management changes unsettling, and new systems and checks were not yet fully established.
“Currently the service does not have a registered manager.” from the report
Falls procedures were not followed
needs fixingAfter a person fell at night, staff did not follow the home's falls procedure or use communication systems effectively. Immediate action was taken and no injury was reported.
“A person had fallen during the night, but staff had not followed the provider's falls management procedure.” from the report
Some hygiene practices needed improvement
minorInspectors found problems with managing soiled laundry and mop heads. The management team agreed to take immediate action.
“This was in relation to managing soiled laundry and mop heads.” from the report
- 01How are medicines now stored so that people cannot access them, and who checks that the medicines trolley is locked?
- 02How do you make sure all required medicine checks, including pulse checks and allergy information, are completed and recorded?
- 03What staffing levels are now considered safe, and how do you cover vacancies and agency shortfalls?
- 04Is there now a registered manager and deputy in post, and how are staff being supported to follow falls and information-sharing procedures?
- 05What changes have been made to the handling of soiled laundry and mop heads?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 20 November 2021 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 2020
Overall rating Requires Improvement; inspectors found good progress, with Safe and Well-led both rated Good.
This was a focused inspection on 26 and 27 August 2020. Inspectors spoke with five relatives, the manager and five staff. They reviewed care records, staff recruitment files, training information and management records.
The home was rated Good for Safe and Good for Well-led. Inspectors found improved risk assessments, care plans, medicines management, infection control, staffing, training and management oversight. Relatives said people were safe and that the home was managed well.
The overall rating remained Requires Improvement because this inspection did not look at all five areas of care. The ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. The home was no longer in breach of the regulations identified at the previous inspection.
Updated risk information
Care plans and risk assessments were reviewed monthly and reflected people's current needs. The home had also assessed the risk of social isolation during the pandemic.
“Care plans and risk assessment information reflected people's current needs.” from the report
Infection control
The home had enhanced cleaning procedures, followed the national testing programme and trained staff in using protective equipment. Inspectors saw staff following the guidance.
“Staff had received updated training on using personal protective equipment (PPE) in line with current government guidance.” from the report
Safe staffing and medicines
Relatives said there were enough staff, and records showed staff had the training needed to manage medicines safely.
“Feedback from people's relatives indicated there were enough staff to provide the care their family member needed.” from the report
Stronger management systems
The home had strengthened its audits, improvement plan and oversight. Staff meetings and handovers helped share information about risks and actions.
“Audits were in place to drive improvements and ensure the service was being run consistently.” from the report
Overall rating remains Requires Improvement
needs fixingThe overall rating did not rise because three areas were not reassessed during this focused inspection. Their previous ratings were used in calculating the overall result.
“The overall rating for the service has remained at requires improvement.” from the report
Fire safety actions still ongoing
needs fixingThe provider was still working with the fire safety team to complete actions identified by a recent audit.
“Following a recent audit by the local fire service, the registered provider demonstrated they were working with the fire safety team to complete the required actions.” from the report
- 01What are the current ratings for Effective, Caring and Responsive, which were not assessed during this inspection?
- 02What actions from the recent fire service audit are still outstanding, and when will they be completed?
- 03How will you keep monthly care plan and risk assessment reviews up to date if my relative's needs change?
- 04How do you check that medicines stock levels and administration records remain accurate?
- 05How will you show that the improvements in management oversight and staff communication are being maintained?
This was a focused inspection of Safe and Well-led, including infection control; the ratings for Effective, Caring and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 11 September 2020 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 Monson Retirement Home
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- November 2021Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Good
- February 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: OutstandingResponsive: GoodWell-led: Good
- April 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 17 November 2011.
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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9 live-in carers within about an hour of Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
“Magda was always positive and proactive about trying new things to keep dad busy. She also introduced new ideas for keeping dad healthy.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.