CQC report explained · a residential care home
What the CQC found at Montrose Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Staffing had increased, call bells were answered promptly, risks were assessed and medicines were managed safely.
- Effective?
- Good
- People's food and drink needs were met, including monitoring for those at risk of malnutrition or dehydration. Staff had training and support, and people were helped to access health professionals.
- Caring?
- Good
- Staff were kind and sensitive. Inspectors saw people's dignity, privacy, choices and involvement in their care being respected.
- Responsive?
- Good
- Care plans reflected people's needs and activities were offered. Complaints were recorded, investigated and responded to under the provider's policy.
- Well-led?
- Good
- The manager and deputy manager were visible and approachable. Daily, weekly and monthly audits were used to identify and complete improvements.
What inspectors found, December 2018
Montrose Care Home was rated Good and is out of Special Measures; inspectors found major improvements in safety, care and management.
Inspectors made a comprehensive, unannounced visit on 26 October 2018. They spoke with people living in the home, relatives and staff. They observed care and checked records, medicines and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines management, better care plans, kind care and improved food and drink support.
The home had been rated Inadequate at the previous inspection in May 2018. It had been placed in Special Measures and restricted from admitting new people without CQC permission. Inspectors found enough improvement for it to leave Special Measures.
Improved staffing and response times
Staffing levels had increased since the previous inspection. Call bells were answered promptly, helping people get support when needed.
“Call bell records we looked at during this inspection showed that call bells were being answered typically in the same minute but no more than three minutes.” from the report
Kind and respectful care
Inspectors saw staff speaking gently, supporting people's choices and protecting their privacy and dignity.
“Staff were seen to be patient and caring and never rushing anyone.” from the report
Improved food and drink support
People reported better menu choices. Staff monitored food and fluid intake where needed and involved health professionals when people were losing weight.
“People told us that they were happy with the food provided and that the menu choices had improved since our last inspection.” from the report
Stronger management checks
The home had introduced regular audits and recorded actions with timescales. Inspectors found these checks were being used to drive improvements.
“During our inspection, we saw that robust auditing system was now in place.” from the report
Privacy and anxiety for one person
needs fixingOne person felt anxious because other people could enter their bedroom. The manager knew about this and was discussing how to resolve it.
“Another person told us they felt safe with staff, however at times they felt anxious because some people in the home were walking about and could enter their bedroom.” from the report
Care plans still being personalised
minorCare plans had improved, but the manager said more work was still needed to include people's preferences, likes and dislikes throughout each plan.
“The manager was working to personalise the care plans even further and ensure that people`s preferences, likes and dislikes were incorporated throughout the care plan.” from the report
Further improvement to hot food service
minorThe home was still working to improve mealtime experiences. A new hot trolley was being purchased so food stayed hot when taken to the top floor.
“The manager told us they were still working to improve people`s meal time experiences further and were purchasing a new hot trolley” from the report
- 01How have the increased staffing levels been maintained, and what are the usual call bell response times now?
- 02How do you prevent people from entering another resident's bedroom and protect their privacy?
- 03How are residents' likes, dislikes and personal preferences recorded and kept up to date in care plans?
- 04Has the new hot trolley been purchased, and how do you check that food is served at a suitable temperature?
- 05How do you review incidents, falls and safeguarding concerns, and what action do you take when patterns are found?
This was a comprehensive unannounced inspection covering the premises and care provided, with ratings given for all five key questions. This explanation was written from the published report of 1 December 2018 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, June 2018
Rated Inadequate and placed in special measures; inspectors found serious failings affecting safety, care planning, staffing and management.
This was an unannounced comprehensive inspection on 16 May 2018. It followed concerns received from members of the public about how risks were managed. The previous inspection in September 2016 had found the service was meeting the required standards.
Inspectors found long waits for call bells, including waits of 14 to 40 minutes. There were many unwitnessed falls and unexplained injuries, but risk assessments and plans to prevent further harm were often missing. Medicines were not always given as prescribed, and safeguarding concerns were not always reported.
Care records were incomplete and did not give staff enough information about people's health, preferences, nutrition or end of life wishes. There were also too few suitable activities. Staff were usually kind, and people said the food was good, but delays and task-focused care affected people's experience.
The overall rating was Inadequate. Safe and well-led were rated Inadequate, while Effective, Caring and Responsive were rated Requires Improvement. The home was placed in special measures and was expected to be inspected again within six months.
Kind staff
People and relatives described staff as kind and respectful. Inspectors also observed staff treating people with kindness and compassion, although delays affected the care provided.
“People told us staff were kind and respectful towards them.” from the report
Food choices
People said the food was good and that they had enough choices. Staff also provided specialist diets, although the related care planning was not reliable.
“People told us they liked the food provided for them and they had enough choices.” from the report
Health support
People said staff arranged GP support and accompanied them to hospital appointments when needed. A visiting health professional also said staff requested GP visits appropriately, although they sometimes called for input too readily.
“People told us that they received good support with their health care needs.” from the report
Long waits for help
seriousPeople sometimes waited a long time for call bells to be answered. Inspectors found repeated delays and periods when communal areas had no staff present.
“We checked a printout of the call bell response times between 24 April 2018 to 16 May 2018 and we found that numerous times it took staff between 14 and 40 minutes to answer call bells.” from the report
Falls and missing risk plans
seriousThere were 33 unwitnessed falls in the period checked, including injuries and fractures. Risk assessments and preventative measures were not put in place for people at risk of falling.
“There were no fall risk assessments carried out for people and no preventative measures were taken to mitigate the risk of falls.” from the report
Medicines errors
seriousMedicine records did not always match the stock available. Some medicines were given at the wrong time, meaning people may not have received them as prescribed.
“This meant that safe medicine administration procedures were not followed and people were at risk of not getting their medicines as intended by the prescriber.” from the report
Incomplete care records
seriousMost care plans checked were only partly completed. They did not give staff enough guidance about risks, health conditions, personal preferences, cultural needs or end of life care.
“We found that out of 14 care plans we checked only two had been partially completed.” from the report
Safeguarding not reported
seriousSome incidents involving injuries or possible abuse were not reported to safeguarding authorities or CQC. The manager reported five concerns after the inspection, and inspectors raised a further four.
“We found that where staff reported and recorded incidents members of the management team failed to raise these with local safeguarding authorities or to CQC.” from the report
- 01How long do people now wait for call bells to be answered, and how is this checked?
- 02What individual risk assessments and prevention plans are now in place for people who have fallen or are at risk of falling?
- 03How do you check that medicines are given at the correct time and that stock matches the records?
- 04Have every person's care plan and risk assessments been completed and reviewed, including nutrition, choking, mobility, seizures and end of life wishes?
- 05How are safeguarding concerns, unexplained injuries and incidents now investigated and reported?
This was a responsive comprehensive inspection covering all five key questions, prompted by concerns about the management of people's care risks. This explanation was written from the published report of 30 June 2018 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Montrose Care Home
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- December 2018Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2018Inadequatedown from GoodSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: GoodWell-led: Requires improvement
- September 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- February 2012
Registered with the Care Quality Commission on 9 February 2012.
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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