CQC report explained · a nursing home
What the CQC found at Montfort Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people felt safe, risks were assessed and managed, staffing was sufficient, medicines were given safely and infection control arrangements were effective.
- Effective?
- Good
- Care needs and preferences were assessed, staff had suitable training and support, and people received appropriate help with food, drink and healthcare.
- Caring?
- Good
- Staff were kind, attentive and respectful. People were supported to make choices, maintain their dignity and remain as independent as possible.
- Responsive?
- Requires improvement
- Activities were not always meaningful or personalised, particularly for people living with dementia. The home also needed to improve its use of pictures and other communication methods.
- Well-led?
- Good
- Inspectors found a positive culture, effective quality checks and good communication. There was no registered manager, but interim arrangements were considered robust and a new manager had been recruited.
What inspectors found, November 2021
Montfort Manor was rated Good overall; inspectors found safe, kind care, but activities and communication for some people needed improvement.
Inspectors visited on 12 and 13 October 2021 without giving advance notice. They spoke with people, relatives and staff, and checked care records, medicines, recruitment files and management records. They also checked infection prevention and control.
The home was rated Good for Safe, Effective, Caring and Well-led. People were protected from abuse, risks were assessed, medicines were managed safely, and staff were trained and available. Inspectors also found kind and respectful care, good support with food and healthcare, and strong management systems.
Responsive was rated Requires Improvement. Activities were not always based on people's interests, especially for people living with dementia. Inspectors also said the home could make better use of pictures and other communication methods. They made recommendations for improvement in both areas.
This was the first inspection after the home was newly registered. There was no registered manager at the time, but interim management arrangements were described as robust, with a new manager recruited.
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding procedures, and individual and environmental risks were assessed and reviewed.
“People and their loved ones we spoke with told us they felt safe living in Montfort Manor and with the staff who cared for them.” from the report
Kind and respectful care
Staff were observed treating people gently and giving them time. People were offered choices and supported with privacy, dignity and independence.
“We observed staff were kind and attentive in their interactions with people.” from the report
Safe medicines and infection control
Medicines were administered by trained staff with checks in place. Inspectors were assured that infection prevention and control arrangements were effective.
“An electronic Medicines Administration Records (MARs) system was used effectively to ensure people received their medicines as prescribed.” from the report
Good management checks
Care records and risk systems were up to date. Audits, surveys and action plans were used to monitor safety and improve care.
“There were robust and effective governance systems in place to ensure high quality and safe care.” from the report
Food and healthcare support
People had meal choices and support with eating and drinking. Staff monitored health needs and worked with healthcare professionals when needed.
“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.” from the report
Activities were not always meaningful
needs fixingActivities did not always reflect people's likes and interests. Inspectors saw limited activity on some floors, and no one from the dementia floor went outside during the day they visited.
“There was a lack of consistent meaningful activities and stimulation, particularly on the floor that looked after people living with dementia.” from the report
Communication methods could be better
needs fixingInformation and menus were mainly written down. People were sometimes asked verbally about meal choices without being shown the options, which could make choices harder for some people.
“Information was displayed around the home to keep people informed, for example about events and activities. However, this was largely in written form” from the report
No registered manager in post
minorThe home did not have a registered manager during the inspection. Inspectors said interim arrangements were robust and a new manager had been recruited.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01How are activities now planned using each person's likes, interests and life history, especially for people living with dementia?
- 02How often are people living with dementia supported to use the garden or go outside?
- 03What pictures, symbols or other communication methods are available for people who find written information or spoken choices difficult?
- 04How are residents shown their meal choices before they decide?
- 05Has the new manager become registered with the CQC, and how is management continuity being maintained?
This was an unannounced first inspection after new registration and covered all five key questions, including infection prevention and control under Safe. This explanation was written from the published report of 19 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, November 2020
Inspected but not rated; inspectors were assured that infection prevention and control measures were in place.
This was an announced inspection on 10 November 2020. It was part of a CQC review of infection prevention and control in care homes during the coronavirus pandemic.
Inspectors found measures for visitors, including screening, masks, hand sanitiser and temperature checks. They were also assured about shielding, social distancing, admissions, protective equipment, testing, cleaning and the infection control policy.
The home was not given an overall rating or a Safe rating. This report looked only at infection prevention and control, so it does not provide a current judgement on other areas of care.
Visitor screening
Visitors were screened, required to wear masks and use hand sanitiser. A temperature-checking device alerted staff to visitors with a high temperature, who were denied entry.
“Visitors were required to complete a Covid-19 screening tool, put on a face mask and use hand sanitiser.” from the report
Hand hygiene training
The home used a UV lightbox to show missed areas of handwashing during staff training and checks.
“The assistant manager used a UV lightbox which identified areas of the hands which might have been missed when washed.” from the report
Infection control leadership
A team leader had a specific role as an infection prevention and control champion and trained staff in good practice.
“A team leader was an Infection Prevention and Control (IPC) Champion.” from the report
Reducing infection spread
The manager said agency nurses were block booked to work in one care setting. Uniforms were washed on site and not taken away from the home.
“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.” from the report
Further development
minorThe CQC signposted the provider to resources to develop its infection prevention and control approach. The report does not give details of what needed development.
“We have also signposted the provider to resources to develop their approach.” from the report
- 01What infection prevention and control resources did the CQC ask you to use to develop your approach?
- 02How do you check that visitors complete screening and use masks and hand sanitiser?
- 03How often are staff's handwashing practices checked using the UV lightbox?
- 04How do you manage testing for people living here and for staff?
- 05How are agency nurses and staff uniforms managed to reduce infection transmission?
This was an announced thematic inspection focused on infection prevention and control during the coronavirus pandemic; the service was inspected but not rated overall or for Safe. This explanation was written from the published report of 26 November 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 Montfort Manor
Each visit the CQC has published, newest first, back to the day the home was registered.
- November 2021Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- November 2020Inspected but not ratedSafe: Inspected but not rated
- October 2019
Registered with the Care Quality Commission on 17 October 2019.
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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