CQC report explained · a residential care home
What the CQC found at Mortain Place Care 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
- Some risks to people's health were not fully identified or managed. Inspectors also found missed medicines, gaps in staff training and staffing levels that did not always support people's personal care.
- Effective?
- Good
- This key question was not inspected during this focused visit. The report does not give a new rating for it.
- Caring?
- Good
- This key question was not inspected during this focused visit. Relatives gave positive feedback about staff being kind and caring, but there was no new rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report does not give a new rating for it.
- Well-led?
- Requires improvement
- Management and quality checks had not consistently identified or corrected risks, record gaps and poor handover information. Leadership had also changed several times in the previous eight months.
What inspectors found, April 2023
Requires Improvement; inspectors found kind care and some safe practices, but risks, medicines, staffing and records were not managed consistently.
This was an unannounced focused inspection after concerns about staffing, risk management and care delivery. One inspector visited on 2, 6 and 12 February 2023, spoke with people, visitors, staff, relatives and healthcare professionals, and checked care records, medicines, recruitment files, the premises and infection control.
The home was rated Requires Improvement overall. Safe was rated Requires Improvement because some health risks were not properly assessed or monitored, some medicines were not given as prescribed, staff lacked some required training, and staffing levels did not always meet people's needs.
Well-led was also rated Requires Improvement. Audits had not found important gaps in care records, handovers and fluid monitoring. The report says the provider breached Regulation 12 on safe care and treatment and Regulation 17 on good governance. The previous overall rating was Good, published on 3 August 2021.
Kind and caring staff
Relatives gave positive feedback about the care and said staff were kind and caring.
“Relatives told us they felt staff were kind and caring.” from the report
Recruitment checks
The home carried out identity, work eligibility, reference and DBS checks before new staff started.
“The provider undertook checks on new staff before they started work.” from the report
Infection control
Inspectors were assured that the home had suitable measures for preventing and managing infections, including safe use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Some risk planning
Inspectors saw good risk management for choking, including modified food and drinks and regular reviews.
“Staff reviewed risk assessments monthly and put actions in place to reduce these risks.” from the report
Partnership working
Staff worked with specialist health professionals and had links with a local hospice to support people at the end of their lives.
“Staff worked closely with speech and language therapists, community rehab teams and occupational therapists to ensure people received the specialist support they needed.” from the report
Health risks were not consistently managed
seriousWeight loss, diabetes, emotional distress and some other health conditions were not always covered properly in care plans or risk assessments. This increased the risk that important changes or complications would be missed.
“Risks to people were not always managed safely, potential risks were not always fully identified, assessed or mitigated.” from the report
Staff training gaps
needs fixingSome staff had not received training needed for people's specific health needs, including catheter care, epilepsy and diabetes.
“Not all staff had received training that was specific to the health needs of people who lived at Mortain Place Care Home.” from the report
Medicines were not always given as prescribed
seriousSome people went without medicines for between three and nine days because of a pharmacy shortage. The records did not explain the impact or fully record discussions with the GP.
“Some medicines had not been given as prescribed.” from the report
Staffing affected personal care
needs fixingSome people did not receive their preferred showers or oral care. Feedback from people and staff suggested that staffing was sometimes too stretched to provide care promptly.
“People did not always receive their preferred personal care, for example, showers and oral health.” from the report
Incomplete care records and handovers
needs fixingCare records did not always contain important health information. Handover sheets and fluid charts were incomplete, which made it harder to track food, drinks and changes in health.
“Handover sheets were not informative and not used effectively.” from the report
- 01What action has been taken to assess and monitor weight loss, diabetes, emotional distress and other health conditions?
- 02How do you make sure staff have training in catheter care, epilepsy and diabetes before supporting people with these needs?
- 03How are medicine shortages handled now, and how do you record the effect of missed doses and discussions with health professionals?
- 04What has changed to make sure staffing is enough for showers, oral care and timely responses to call bells?
- 05How do you now check that handovers, fluid charts and care plans are complete and up to date?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 6 April 2023 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 2021
Mortain Place Care Home was rated Good overall, but inspectors found that leadership and care records needed improvement.
Inspectors made an unannounced visit over three days in June 2021. They spoke with people, relatives, staff and health professionals. They observed care and reviewed care plans, medicine records, recruitment files, training records and management documents.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough suitably trained staff, safe medicines practice, kind and respectful care, good food and support for people's choices, relationships and activities.
Well-led was rated Requires Improvement. Some records did not clearly show changes in people's health, mental health, oral care, weight or daily support. The management team had identified some problems and took action during the inspection, but some issues were not fully resolved.
This was the first inspection since the service registered in 2019. The overall Good rating means inspectors found good care overall, but the home did not meet the higher standard in every area.
Enough trained staff
Inspectors found consistent staffing levels and an appropriate mix of skills. Staff were recruited safely and received training, induction and supervision.
“There were enough staff to meet people's needs.” from the report
Safe medicines
Medicines were stored, given and disposed of safely. Staff who administered medicines had training and competency checks.
“Medicines were given safely to people by competent and knowledgeable staff, who had received appropriate training.” from the report
Kind and respectful care
People were treated with kindness and respect. Staff promoted privacy, dignity, independence and people's involvement in decisions.
“Everyone we spoke to was consistent in their views that staff were kind, caring and supportive.” from the report
Food and healthcare support
People were offered choices of food and drink, and staff knew their dietary needs. The home worked with healthcare professionals and helped people attend appointments.
“People's nutritional and health needs were consistently met with involvement from health and social care professionals.” from the report
Family contact and activities
Visitors were welcomed under the infection control arrangements. People were supported to keep in touch with family and take part in varied activities.
“The planned activity programme was varied and displayed on notice boards throughout the home.” from the report
Care records were not always accurate
needs fixingSome care plans did not contain current guidance about health needs such as oral care, mental health, weight loss and other conditions. This meant changes were not always planned for and monitored effectively.
“There was a lack of clear and accurate records regarding changes to people's health and well -being, for example oral care.” from the report
Known audit issues were not fully resolved
needs fixingAudits had identified incomplete fluid charts and weak care plan reviews, but inspectors found these problems were still present. Some people staying in their rooms or on bedrest had no record of one-to-one activities or staff interaction.
“However, we found that these issues were not yet fully resolved.” from the report
Mental health changes were not always followed up
needs fixingWhen people became withdrawn, lost their appetite or stayed in bed, staff did not always monitor them or seek professional advice. A plan was not always made to manage these changes.
“People whose mental health had deteriorated, for example, taking to bed, losing their appetite and becoming withdrawn had not always been monitored and advice sought from health professionals.” from the report
- 01How are you making sure care plans are updated promptly when a person's health, mental health, weight or oral care changes?
- 02What checks now confirm that fluid charts and oral health records are complete and accurate?
- 03How do you monitor people who become withdrawn, stay in bed or lose their appetite, and when do you seek professional advice?
- 04How do you record one-to-one activities and staff contact for people who spend most of their time in their rooms?
- 05What actions have been completed since the inspection to address the issues identified in the quality audits?
This was an unannounced first inspection that assessed all five CQC questions and included infection prevention and control arrangements, so there were no previous ratings to carry over. This explanation was written from the published report of 3 August 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.
Every inspection of Mortain Place Care Home
2 rated inspections over 2 years: the service has slipped, from Good to Requires improvement.
- April 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2021GoodSafe: GoodWell-led: Requires improvement
- September 2019
Registered with the Care Quality Commission on 27 September 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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19 live-in carers within about an hour of East Sussex
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.
Most charge £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
“When he point blank refused to go into hospital for a life saving blood transfusion she talked him through the situation and agreed to go in the ambulance with him and stayed until he was settled.”
“Una felt safe, secure and loved in her time with Debbie which is a gift that I am eternally grateful for.”
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