CQC report explained · a nursing home
What the CQC found at Mount Elton Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2021
Mount Elton Nursing Home was inspected but not rated; inspectors found infection-control and recruitment shortfalls, with some action taken after the visit.
This was an announced, targeted inspection on 18 December 2020. Inspectors looked only at Safe and Well-led, after concerns about infection control, safeguarding, staff recruitment and governance. One inspector carried out the visit.
Inspectors found that people and staff felt safe. They were assured that most infection-control arrangements were working, including PPE, hand hygiene, cleaning, testing, visiting arrangements and social distancing. The home was clean and free from odours.
There were shortfalls. Some staff had not completed COVID infection-control or recent safeguarding training. Some COVID risk assessments had not been completed, and recruitment records and DBS checks were not always up to date. The provider said it took action after the inspection.
The home was not given ratings for Safe or Well-led, and there was no overall rating from this inspection. The previous breach of Regulation 17 had been addressed, so the home was no longer in breach of that regulation at this visit.
People felt safe
People, relatives and staff told inspectors that people were safe. Staff were described as friendly, supportive, kind and caring.
“People and staff felt safe and all felt the service was a nice place.” from the report
Infection-control arrangements
Inspectors were assured about PPE, hand hygiene, visiting arrangements, social distancing, testing and the prevention of infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Clean environment
Extra cleaning focused on areas often touched, and inspectors found the home clean and free from odours.
“Additional cleaning regimes were in place to ensure a high standard of cleanliness” from the report
Family contact
The home supported people to keep in touch with their families, including visits for people receiving end-of-life care.
“People supported to keep in touch with families. This had included outside visits and inside visits” from the report
Improved governance
The provider had improved its systems since the previous inspection and was no longer in breach of the earlier governance regulation.
“At this inspection improvements had been made and the provider was no longer in breach of this regulation.” from the report
Staff training
needs fixingAt the inspection, staff had not received specific COVID infection-control training, and not all staff had received recent safeguarding training. The provider said these issues were addressed or planned afterwards.
“staff had not received any specific training relating to coronavirus infection prevention control at the time of the inspection.” from the report
Recruitment records
seriousSome staff files were incomplete. One file had no employment record, application form, DBS check or references.
“one member of staff had no record of their employment, this included a contract, application form, disclosure and barring service and references.” from the report
Out-of-date DBS checks
seriousSome DBS checks were more than five years old, with some dating back to 2002 or 2003. There was no system to ensure newer checks were completed.
“some of those DBS checks had been undertaken over 5 years ago and no further or recent checks had been undertaken” from the report
Positive COVID test response
seriousAfter one staff member tested positive, the provider retested them instead of following the guidance described in the report about self-isolating at home.
“where one member of staff had tested positive the provider had not followed government guidance” from the report
- 01Have all staff now completed COVID infection-control training and the planned safeguarding refresher training?
- 02How do you make sure every staff member has the required contract, application, references and DBS check before working with residents?
- 03How often are DBS checks reviewed, especially for staff whose checks are more than five years old?
- 04What is the current procedure when a staff member tests positive for COVID-19?
- 05How do your audits now identify missing staff records, risk assessments and training?
This was a targeted inspection of Safe and Well-led only; the other key questions were not inspected and were not rated. This explanation was written from the published report of 4 February 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 2019
Rated Requires Improvement; inspectors found kind and personalised care, but safety checks, medicines and management oversight were not reliable enough.
Inspectors visited the home over three days in September 2019. The first day was unannounced. They spoke with people, staff, relatives and a health professional. They also reviewed care plans, staff files, medicines, complaints, incidents and management records.
People generally received kind care and had their choices, privacy and independence respected. Care plans covered individual needs, activities and end of life wishes. Staff received training, supervision and appraisals.
There were important safety problems. Medicines records were not always accurate, two medicines were out of date, some recruitment checks were incomplete, and parts of the building and equipment were not always safe. Lunch support was also inconsistent.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. Effective, Caring and Responsive remained Good.
Kind and respectful care
People said staff were kind and polite. Inspectors found that staff understood privacy, dignity and independence.
“People were support by staff who were kind and caring and who treated them well.” from the report
Personalised care planning
Care plans included people's likes, dislikes, routines, communication needs, religious needs and end of life wishes. They were reviewed when needed.
“People's care plans were person centred and contained important information on people's likes and dislikes and their preferred routines.” from the report
Staff training and support
Staff received relevant training, supervision and annual appraisals. They also had access to the care certificate.
“Staff received training to ensure they were skilled and knowledgeable within their role.” from the report
Good handling of incidents
Incidents and accidents were recorded and reviewed for patterns. Actions were recorded to help improve care.
“All incidents were reviewed for any trends and patterns action taken were recorded.” from the report
Medicines safety
seriousTwo medicines were out of date and medicines records were not always accurate. Guidance and records for creams and thickener were also incomplete.
“People were not always receiving their medicines safely due to stock being out of date and records being inaccurate.” from the report
Environmental risks
seriousSome windows opened too far, some radiators were uncovered and one sluice room was unlocked despite containing hazardous cleaning substances. The home said it took action after the inspection.
“The sluice room door was found to be unlocked throughout the inspection.” from the report
Recruitment checks
seriousTwo staff had started before satisfactory checks or references were in place, and there was no risk assessment for one of them.
“People were not always supported by staff who had checks completed prior to working with vulnerable adults.” from the report
Weak management checks
seriousThe home's audits did not identify several safety and record-keeping problems. This was the reason for the breach of Regulation 17.
“Audits and checks in place had failed to identified shortfalls found during our inspection.” from the report
Inconsistent help at mealtimes
needs fixingPeople needing help with meals were sometimes supported by different staff during the same meal. Inspectors asked the manager to review this practice.
“The support people received over their lunchtime experience was inconsistent.” from the report
- 01What checks now make sure medicines are in date, records are accurate, and cream and thickener instructions are followed?
- 02Have all window restrictors, radiator covers, sluice-room locks, bed rail bumpers and mattress-setting checks been completed?
- 03How do you make sure every new staff member has satisfactory DBS checks, references or a documented risk assessment before starting?
- 04How do you make sure one consistent staff member supports each person throughout a meal when they need help?
- 05What new audits are now used to find problems with care records, medicines, equipment and the environment?
This inspection covered all five key questions and reviewed care, staffing, medicines, the environment and management systems; the report lists the visits as 3, 4 and 6 September 2019, while another section refers to 3, 4 and 9 September. This explanation was written from the published report of 20 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 Mount Elton Nursing Home
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
- November 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 7 February 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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23 live-in carers within about an hour of North Somerset
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 £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.