CQC report explained · a nursing home
What the CQC found at Mortimer House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improvements in staffing and supervision, safe recruitment, safeguarding and medicines administration. They noted high use of agency staff, some incomplete medicine paperwork and variable risk assessments.
- Effective?
- Good
- Staff had relevant training and supervision, and people received support with eating and drinking. Inspectors noted concerns about recording annual health checks and meeting all conditions on DoLS authorisations.
- Caring?
- Good
- Staff were kind, respectful and patient. They knew people's personalities, preferences and ways of communicating, and supported independence and privacy.
- Responsive?
- Good
- Care plans were person-centred and explained people's routines, choices and support needs. Inspectors noted some periods without organised activities and that most end of life plans contained very few details.
- Well-led?
- Requires improvement
- The home had an action plan and support from the provider and another home, and improvements had been made. However, care records still contained inconsistencies and the management and leadership were not consistent in all areas.
What inspectors found, December 2019
Rated Good overall, but inspectors found the home was not well-led in all areas and needed more consistent records.
The inspection was unannounced and took place on 11 November 2019. One inspector and a learning disability nurse reviewed records, medicines, quality and safety monitoring. They spoke with the manager and six staff, and observed people's care because people could not give verbal feedback.
The home cared for 20 people with learning difficulties and/or dementia, and could support up to 28 people. Inspectors found people were safe, received effective care, were treated kindly, and had their needs met. Staffing had improved, although there was still high use of agency staff and some vacancies.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led was rated Requires Improvement because records were not always consistent and some systems still needed strengthening. The home had improved since the previous inspection, when the overall rating was Requires Improvement.
Kind and respectful care
Inspectors observed staff treating people with kindness, dignity and respect. People were not rushed during personal care or meals.
“People received care from staff who were kind and caring in their approach.” from the report
Improved safety
The home had improved its staffing arrangements and handovers since the earlier inspection. Inspectors found it was no longer in breach of the safety regulation.
“At this inspection we found improvements had been made and the service was no longer in breach of this regulation.” from the report
Personalised support
Care plans described people's preferences, routines and required levels of support. Staff were able to explain what mattered to the people they supported.
“People had clear and well written support plans in place that were person centred in nature and reflected their preferred ways of being supported.” from the report
Staff training and support
Staff said they were satisfied with their training and support. Records showed training covered areas relevant to the needs of people living at the home.
“Staff told us they were happy and satisfied with their training and support.” from the report
Inconsistent care records
needs fixingSome care records did not match people's current needs or the care being provided. Inspectors recommended keeping records under review so changes were recorded consistently.
“We recommend that care records are kept under review to ensure they are consistently updated when people's needs change.” from the report
DoLS conditions
needs fixingThe home still could not show that all conditions on people's DoLS authorisations had been met. The provider had identified this and was reviewing people's files.
“At this inspection we found that this continued to be a concern.” from the report
Incomplete medicines paperwork
needs fixingInspectors found safe medicines administration, but said agency nurses had not always signed documents when restocking medicines. Some paperwork about medicines being crushed or placed on jam was also awaiting a signature.
“There were safe procedures in place for checking new medicines in to the service although we were told that on occasion agency nurses hadn't always followed established procedures for signing documents when restocking medicines.” from the report
Limited end of life plans
needs fixingMost end of life planning documents contained very few details. Inspectors said more work would be useful to make sure people's needs were met at this stage.
“We saw evidence of an end of life planning document in people's care files, however in most cases this contained very few details.” from the report
- 01How are you making sure care plans and risk assessments are updated promptly when a person's needs or health changes?
- 02What work has been completed to meet all conditions on people's DoLS authorisations?
- 03How do you check that agency nurses follow the home's medicines recording and restocking procedures?
- 04How are you reducing the use of agency staff and filling the remaining vacancies?
- 05How will you develop people's end of life plans when they have complex communication needs?
This was an unannounced inspection covering all five CQC questions, with observations, discussions and reviews of five people's care records, medicines records and quality and safety documents. This explanation was written from the published report of 21 December 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.
What inspectors found, November 2019
Mortimer House rated Requires Improvement; inspectors found risks in staffing, safeguarding follow-up and management systems, although care was kind.
This was an unannounced, focused inspection on 7 August 2019. Inspectors looked only at whether the home was Safe and Well-led. They spoke with people, a relative and staff, and checked records and management systems.
Inspectors found that people were not always protected from avoidable risk. A safeguarding concern had not initially been dealt with. There was no handover at lunchtime, and a lounge was left unsupervised for several minutes while permanent staff attended a meeting. Four new staff had also not completed the full induction programme.
Staff were kind and caring, and people said they felt happy living at the home. Medicines, infection control and accident recording had improved. However, the overall rating remained Requires Improvement, as did Safe and Well-led. The home had received this rating at its last four inspections.
Kind and caring staff
Inspectors found staff were kind and supported people promptly. People said they felt happy living at the home.
“Staff were kind and caring. They supported people with their needs promptly.” from the report
Medicines improved
Problems identified at the previous inspection had been addressed. Medicines were stored safely and checks were completed.
“People now received safe support with medicines. Medicines were stored safely in a locked room, so they were only accessible to people authorised to do so.” from the report
Incident monitoring
Accidents and incidents were recorded and reviewed to look for patterns and possible lessons.
“To learn lessons when things went wrong accidents and incidents were recorded reviewed and monitored.” from the report
Good relationships
People and a relative reported good relationships with staff and management. People were involved in care reviews and decisions.
“People said they had good relationships with staff and the management team.” from the report
Safeguarding was not dealt with promptly
seriousA safeguarding allegation raised internally had not been addressed before a further serious allegation was made. The provider and local authority were investigating, and the staff member concerned no longer worked at the home.
“Before our visit a safeguarding allegation had been reported internally by a member of staff. This had not been addressed.” from the report
Unsafe staffing arrangements
seriousAll permanent staff attended a meeting at the same time. Agency staff were left supporting people, and a lounge was unsupervised for several minutes.
“This left a lounge unsupervised for several minutes. The lounge was occupied by several people.” from the report
No lunchtime handover
seriousStaff coming on duty at 1pm did not receive a handover about changes in people's needs. Inspectors said this could lead to unsafe care.
“At 1pm the afternoon staff came on duty. We saw that there was no handover between the morning staff and the new staff.” from the report
Incomplete staff induction
seriousFour new staff had completed moving and handling training but had not completed other training relevant to their roles.
“However, four new staff had not done the staff induction programme.” from the report
Management checks had not fixed known problems
seriousAudits were not fully effective because known concerns, including induction and handover arrangements, had not been acted on.
“The audits completed by the manager since the last inspection in September 2018 were not fully effective.” from the report
- 01How are you making sure a lounge is supervised when staff attend meetings or need help with another person?
- 02What is the current process for reporting and responding to safeguarding concerns, and how quickly are they reviewed?
- 03Does every shift now receive a handover at 1pm, and how do you check that important changes in people's needs are passed on?
- 04Have all new staff completed the full induction and role-related training, and how is this recorded?
- 05What evidence can you show that the action plan and new management checks have improved safety and governance?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 5 November 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 Mortimer House
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- December 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- June 2011
Registered with the Care Quality Commission on 13 June 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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