CQC report explained · a nursing home
What the CQC found at Montgomery House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about most infection prevention measures, including visitors, admissions, testing, cleaning and the infection control policy. They were not always assured that PPE was used effectively or that outbreaks were fully prevented.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed as a separate rated question. Inspectors found that the provider had a COVID-19 risk assessment and knew how to access infection control advice.
What inspectors found, April 2022
Inspected but not rated; inspectors found generally good COVID-19 controls but some PPE and staff-break risks.
This was an unannounced, targeted inspection. Inspectors looked at infection prevention and control during a COVID-19 outbreak, visiting arrangements and whether staffing pressures affected care.
The home was clean, uncluttered and well ventilated. Inspectors found suitable PPE, safe admission arrangements, testing and isolation measures. Families were given visiting rules, including PPE and negative test requirements.
There were two shortfalls. Two staff members and one contractor were not wearing PPE as required. Three staff from different units took their breaks together, creating a risk of spreading infection between units. These issues were addressed after inspectors raised them.
The service was inspected but not rated. This means the visit did not provide a full new quality rating for the home.
Clean environment
The home appeared clean, uncluttered and well ventilated. Cleaning continued during the inspection, and rooms were deep cleaned after positive COVID-19 tests.
“The home appeared clean and hygienic and cleaning was ongoing throughout the inspection.” from the report
COVID-19 planning
The home had a detailed risk assessment for dealing with a COVID-19 outbreak and had access to local infection control advice.
“A thorough corporate risk assessment was in place specific to COVID-19 that gave clear guidance on how to deal with a COVID-19 outbreak.” from the report
Safe admissions and visits
Admissions followed current guidance, with extra checks where needed. Visiting rules were communicated to families and included protective equipment and negative test evidence.
“People were admitted to the home in line with current admissions guidance.” from the report
Support for staff
Staff could use an employee assistance programme and the provider's human resources team. Staff absent because of COVID-19 were paid in full.
“Staff had access to an employee assist programme and the provider's human resources department if they needed additional support.” from the report
PPE was not always used correctly
needs fixingTwo staff members were not wearing fluid-resistant masks and one contractor was not wearing PPE in line with guidance. The issue was addressed immediately during the inspection, with further action reported afterwards.
“We were not always assured that PPE was used effectively.” from the report
Risk of infection spreading between units
needs fixingThree staff working across different units took their breaks together in one room. This created a risk of cross-contamination when they returned to their separate units.
“This meant there was a risk of cross contamination and spread of infection across the home” from the report
- 01How do you now check that every staff member and contractor wears the correct PPE?
- 02How are staff breaks organised so that workers from different units do not mix?
- 03What action was taken after the inspection, and how was it checked?
- 04How are visiting rules and COVID-19 testing requirements currently communicated to families?
- 05What are the home's current staffing levels and how are COVID-19-related staff pressures managed?
This was an unannounced targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other quality questions were not assessed. This explanation was written from the published report of 5 April 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, August 2019
Rated Good overall; inspectors found safe, kind and responsive care, but the home’s leadership and checking systems still required improvement.
This was an unannounced inspection over two days in July 2019. Inspectors spoke with people living in the home, relatives, staff and a visiting health professional. They reviewed care files, staff recruitment records, audits, complaints and maintenance records, and observed care.
The home was rated Good for Safe, Effective, Caring and Responsive. People were protected from abuse and avoidable harm, received medicines as prescribed, and had enough staff support. Inspectors found kind care, involvement in decisions, personalised support, activities and access to health services.
Well-led was rated Requires Improvement. Some important information was missing from care records, some monitoring charts had gaps, and the home’s checks had not found these issues before the inspection. Inspectors also received mixed feedback about how approachable some staff were.
The overall rating improved from Requires Improvement at the previous inspection. The home was no longer in breach of Regulation 17, although well-led remained Requires Improvement because management systems were not fully embedded.
Safe care and medicines
People had person-centred risk assessments, sufficient staff and systems for giving and checking medicines. Accidents and incidents were investigated and reviewed.
“People were protected from harm by staff who had been trained in safeguarding.” from the report
Kind and respectful care
Inspectors saw staff taking time with people and not rushing them. People were involved in decisions, and their privacy, dignity and independence were supported.
“People were treated with kindness and respect. People were involved in decisions about their care.” from the report
Personalised support and activities
Care plans reflected people’s needs, backgrounds and communication needs. People could take part in varied activities, community outings, therapy sessions and social events.
“Activities offered to people were meaningful and varied.” from the report
Improved performance since the previous inspection
Safe, Effective, Caring and Responsive improved from Requires Improvement to Good. The previous governance breach had also been resolved.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulation.” from the report
Management checks missed gaps
needs fixingSome care records did not contain enough guidance, and some monitoring charts had gaps. These issues were dealt with during the inspection, but the home’s own checks had not identified them beforehand.
“the systems and processes in place had not picked up on these prior to our visit.” from the report
Mixed feedback about approachability
minorPeople and staff gave feedback that some staff were not always approachable. The manager said this was an historical issue being addressed.
“we received feedback from both people and staff which questioned the approachability of certain staff within the service.” from the report
Information sharing needed improvement
minorCommunication with some health care teams needed more attention so that information was shared and recorded consistently.
“communication between the service and some health care teams needed further attention to ensure there was a more joined up approach to the sharing of information.” from the report
- 01How do you now check that risk assessments contain enough detail, including guidance for people at risk of self-harm?
- 02How do you make sure monitoring charts and daily care records are complete and reviewed?
- 03What has been done to improve the approachability of staff identified as a concern in the inspection?
- 04How do you share information consistently with outside health care teams?
- 05How will you show that the improvements in governance systems are fully embedded?
This was an unannounced inspection covering all five CQC questions, including the care provided and the premises; the previous inspection’s Regulation 17 breach was reviewed. This explanation was written from the published report of 31 August 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 Montgomery House
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- April 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2016
Registered with the Care Quality Commission on 19 October 2016.
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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