CQC report explained · a residential care home
What the CQC found at Mount Pleasant House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, July 2023
Mount Pleasant House was rated Requires Improvement; inspectors found kind care but serious gaps in medicines, staffing, records and management oversight.
This was an unannounced inspection on 19 April 2023. Inspectors observed care, spoke with people, relatives and staff, and checked care records, medicines, staff files and management records. The inspection followed concerns about frequent management changes and their effect on care.
The home was not always safe or effective. Some risks were not assessed, care plans were not updated when needs changed, and medicines records and guidance were incomplete. Staff said there were not enough staff for all duties, and training and supervision had gaps.
Inspectors also found kind and respectful interactions. People generally felt safe, liked the food, received help from health professionals and were supported to make choices. However, management systems did not reliably identify or fix problems.
The overall rating fell from Good at the previous inspection, published on 29 November 2018, to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. The report did not give ratings for Caring or Responsive.
Kind core staff team
People and relatives generally felt well cared for. Inspectors observed kind, respectful interactions and found that staff knew people well.
“People using the service and their relatives told us they felt they were cared for by the core staff team who were skilled, caring and respectful.” from the report
Safeguarding
Staff understood how to recognise, report and escalate concerns about abuse or harm. People and relatives said they felt safe.
“The service had effective safeguarding systems in place and staff had a good understanding of what to do to make sure people were protected from harm.” from the report
Health support
Staff recognised changes in people's health and worked with health professionals. Relatives generally felt concerns were identified and acted on quickly.
“Staff were proactive in making timely referrals to health professionals when they had concerns around people's health and well-being.” from the report
Food and choice
People enjoyed the food and had choices about meals, drinks and where to eat. Staff knew people's dietary preferences and offered alternatives when meals were declined.
“People were given choices of what to eat and drink. The food provided was well presented and kept warm.” from the report
Medicines records and guidance
seriousMedicine records were incomplete and stock counts did not always match the records. There was also no clear guidance for some as-needed medicines, including recording why they were given and whether they worked.
“MAR sheets were not always accurate, there were some gaps on MARs when medicines had not been administered but no explanation was recorded.” from the report
Unassessed risks and outdated care plans
seriousSome falls risks and risks linked to distress were not properly assessed. Care plans were not always updated when people's needs changed, which could result in inconsistent care.
“People's risks in areas such as falls had not always been assessed.” from the report
Staffing levels
seriousStaff said there were not enough people on duty for all tasks, including when two staff were needed for personal care. The provider had no tool to calculate staffing against people's current needs.
“The provider did not take appropriate steps to ensure there were sufficient numbers of suitably qualified, skilled and experienced staff to provide support to people using the service.” from the report
Training and supervision
needs fixingChanges in management had affected staff support, training and opportunities to discuss development needs. Records showed gaps in supervision and training.
“Supervision and training matrixes confirmed there were gaps in this provision.” from the report
Management oversight and communication
needs fixingThere had been repeated manager changes and audits did not identify important problems. Relatives also said information and communication were poor.
“Audits were not effective in identifying areas for improvement.” from the report
- 01What action has been taken to make sure medicines received, administered, declined and given as needed are recorded correctly?
- 02Which current risk assessments and care plans have been updated, particularly for falls, distress and eating and drinking needs?
- 03How do you now calculate staffing levels, including at night and when two staff are needed for personal care?
- 04What training, supervision and competency checks have staff completed since the inspection?
- 05How are relatives now kept informed about management changes and their family member's care?
This was an unannounced inspection prompted by concerns about leadership and oversight; it rated Safe, Effective and Well-led, while Caring and Responsive were not given ratings. This explanation was written from the published report of 1 July 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, November 2018
Rated Good; inspectors found safe, kind care and clear improvements since the previous inspection.
This was an unannounced comprehensive inspection on 31 October 2018. Inspectors spoke with seven people living at the home, five relatives, the manager and eight staff. They also looked at the building, care practices, care records, staff files, rotas, training and other records.
The home was rated Good overall, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and were happy with their care. Inspectors saw respectful staff, well-managed medicines, suitable staffing and care that met people's needs.
The inspection checked improvements needed after September 2017. The home had improved its mental capacity work, risk assessments, personalised care records, activities and quality checks. The report says all outstanding legal requirements from the previous inspection had been met.
Improvement since 2017
The home had acted on all the areas identified at the previous inspection, including legal decision-making, risk assessments, care records, activities and quality monitoring.
“At this inspection we found improvements had been made in all the areas identified at the previous inspection.” from the report
Safe medicines management
Medicines were stored securely, records were completed and checks were carried out. Staff responsible for medicines had relevant knowledge and training.
“Medicines were securely stored and people were supported to take the medicines they had been prescribed.” from the report
Kind and respectful care
Inspectors observed staff being patient, discreet and attentive. People were involved in decisions and their privacy was respected.
“The care we observed being provided throughout the inspection was appropriate to people's needs and supported their well-being.” from the report
Personalised support
Updated care records included information about people's lives, preferences, communication needs and how staff should support them.
“This document provided more detailed information specifically about the person, their life, people who were important to them and their preferences, routines and more about their personality.” from the report
Learning from incidents
Accidents and incidents were recorded and reviewed. The home made changes where needed to reduce risks, including seeking professional advice after falls.
“An audit system identified any patterns or trends which could be addressed, and subsequently reduce any identified risks.” from the report
Room numbering
minorRoom numbers were not in sequence, which inspectors said could have caused confusion. People living there were able to find their rooms, and the manager said they would consider changing the system.
“Room numbers were not in sequence order which could have confused people.” from the report
- 01How will you make sure care plans continue to reflect my relative's changing needs and personal preferences?
- 02How do you assess whether activities suit each person, including people who prefer quiet time or do not enjoy group games?
- 03How will you manage any risks specific to my relative, and how often will their risk assessments be reviewed?
- 04How will you involve my relative and our family in decisions if they may lack capacity to make a particular decision?
- 05How do you check that medicines are stored, administered and recorded safely for each person?
This was a comprehensive inspection covering all five CQC questions and checking improvements required after the September 2017 inspection. This explanation was written from the published report of 29 November 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.
Every inspection of Mount Pleasant House
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 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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