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CQC report explained · a residential care home

What the CQC found at Mount Pleasant Residential Home

Goodpublished 13 May 2022, 4 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found that risks were identified and reviewed, medicines were managed safely, recruitment checks were completed and infection control systems had improved.
Effective?
Good
This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
Caring?
Good
This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
Responsive?
Good
This key question was not inspected during this focused visit. Its previous rating was used to calculate the overall rating.
Well-led?
Requires improvement
Governance and audit systems had improved, but inspectors said the home needed a longer-term record showing that improvements and good practice were sustained.
The latest report, explained

What inspectors found, May 2022

Rated Good after major improvements; Safe was Good, but Well-led Requires Improvement and the home has only recently left Special Measures.

This was an unannounced, focused inspection carried out on 17, 22, 23 and 29 March 2022. Two inspectors spoke with people, staff and relatives, and checked medicines, care records, audits, incidents, maintenance and staff files.

Inspectors found major improvements since the previous inspection. The home was clean, staffing levels supported cleanliness, risks were reviewed, medicines were managed safely and infection control had improved. People said staff were kind, responsive and listened to them.

Safe was rated Good. Well-led was rated Requires Improvement because the home needed to embed its audit systems and show a longer record of sustained improvement. The overall rating became Good, but the other three areas were not inspected and their previous ratings were carried forward.

What inspectors praised
  • Safer environment

    The home had undergone major refurbishment. Inspectors found it visibly clean, with enough housekeeping cover and safety checks in place.

    “All areas of the service were visibly clean and enough housekeeping cover was now in place.” from the report
  • Medicines improved

    Records for medicines given when needed were clear and consistent. Prescribed creams were stored securely and staff followed safe medicines procedures.

    “The management and administration of medicines had improved and was robust with clear procedures in place.” from the report
  • Kind and responsive staff

    People told inspectors they felt cared for and listened to. They described staff as kind and responsive.

    “People who used the service told us they felt well cared for and listened too.” from the report
  • People involved

    The home held meetings and used surveys and conversations to seek the views of people and relatives.

    “The service sought feedback and encouraged involvement in several ways including meetings, surveys and regular conversations with people and their relatives.” from the report
What inspectors were concerned about
  • Leadership needs to prove improvements will last

    needs fixing

    Well-led was rated Requires Improvement. Inspectors found significant progress, but said audit systems needed to become established and the home needed a longer record of sustained improvement.

    “To improve the rating to 'good' would require the embedding of audit systems and a longer-term track record of sustained improvement and good practice.” from the report
Questions to ask them, based on this report
  1. 01How will you show that the improved audit and governance systems continue to work over time?
  2. 02What checks are now used to make sure medicines given when needed are recorded correctly?
  3. 03How do you check that staffing levels remain sufficient to keep the home clean?
  4. 04How are relatives involved through meetings, surveys and regular conversations?
  5. 05What were the ratings and any concerns from the previous inspection in the Effective, Caring and Responsive areas?

This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 13 May 2022 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.

An earlier report, explained

What inspectors found, October 2021

Overall Inadequate and in special measures; inspectors found unsafe medicines, infection control and risk management, with poor oversight of the home.

This was a focused inspection on 05 and 07 May 2021. Inspectors checked whether the home had followed its improvement plan and met legal requirements for Safe and Well-led care. They spoke with people, staff and relatives, observed care, and reviewed care, medicines, staff and management records.

The home was rated Inadequate for Safe and Well-led. Inspectors found continued problems with medicines, prescribed creams, infection control, cleaning, locked doors, harmful products and incomplete risk assessments. Care plans and records were not always accurate or person-centred.

The provider had been in breach of regulations since June 2015, and this was the eighth inspection in a row rated no higher than Requires Improvement. Some immediate actions were taken during or after the inspection, but the inspectors found that improvements had not been sufficient or sustained.

The home remains in special measures. This means the CQC will keep it under review and normally re-inspect within six months. If there is still an Inadequate rating, the CQC may begin action to prevent the provider from operating the home.

What inspectors praised
  • Safeguarding

    People were protected from abuse. Staff had training and knew how to report concerns.

    “People were protected from abuse by staff who had received training and had access to appropriate policies and guidance.” from the report
  • Recruitment

    The recruitment checks reviewed by inspectors were appropriate and aimed to ensure suitable staff were employed.

    “Recruitment processes were safe. Appropriate pre-employment checks were carried out to ensure that only suitable people were employed.” from the report
  • Trained medicines staff

    People received their regular medicines from trained staff, although inspectors found problems with some medicines records and risk assessments.

    “People received their regular medication from appropriately trained staff.” from the report
  • Professional working

    The home worked with healthcare professionals, and professionals said staff followed their recommendations.

    “Healthcare professionals told us that their recommendations to staff about how to support a person were followed.” from the report
  • Approachable management

    Inspectors found the management team approachable and responsive when concerns were raised. Some relatives also spoke positively about their relationships with the home.

    “The registered manager and nominated individual were approachable and responsive to feedback throughout the inspection.” from the report
What inspectors were concerned about
  • Medicines and creams

    serious

    Records and risk assessments for as-required medicines and prescribed creams were incomplete. Body maps were not consistently signed, dated or reviewed.

    “Risks relating to safe storage and administration of medicines were not fully assessed and managed.” from the report
  • Infection control and cleanliness

    serious

    Some areas, bathrooms and equipment were unclean. Used and unused protective equipment was not always handled or stored safely.

    “Systems were either not in place or robust enough to demonstrate that risks associated with infection control and the environment were safely managed.” from the report
  • Environmental risks

    serious

    Cleaning chemicals were accessible, and doors to the laundry room and outside were left unlocked. Inspectors also found an unsafe radiator and missing testing records.

    “Harmful products such as bleach were not stored safely and were left in communal areas.” from the report
  • Care records

    needs fixing

    Care plans and risk assessments varied in quality and were not always reviewed. Some records did not show clearly whether people had received the care they needed.

    “Records in relation to people's care did not always contain adequate information and were not always completed properly.” from the report
  • Repeated management failures

    serious

    The provider's audits and action plan had not found or fixed repeated problems. The home had been rated no higher than Requires Improvement at eight consecutive inspections.

    “There had not been sufficient and sustained improvements in the oversight of the safety and quality of the service being provided for people.” from the report
Questions to ask them, based on this report
  1. 01What has changed since this inspection to make medicines and prescribed creams safer, and how are body maps and as-required medicine records now checked?
  2. 02How are cleaning standards, protective equipment storage and disposal, and bathroom hygiene monitored each day?
  3. 03How are bleach and other harmful products kept locked away, and how are external and laundry-room doors kept secure?
  4. 04What evidence can you show that care plans and risk assessments are now reviewed and written in a person-centred way?
  5. 05What actions have been completed since the home was placed in special measures, and what is still outstanding?

This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings were not assessed in this report. This explanation was written from the published report of 30 October 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.

The story over the years

Every inspection of Mount Pleasant Residential Home

10 rated inspections over 7 years: the service has improved, from Requires improvement to Good.

  1. May 2022Goodcurrent ratingup from Inadequate
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Mount Pleasant Residential Home →

  2. October 2021Inadequatestayed Inadequate
    Safe: InadequateWell-led: Inadequate

    Read what inspectors found at Mount Pleasant Residential Home →

  3. January 2021Inadequatedown from Requires improvement
    Safe: InadequateWell-led: Inadequate

    Read this report on cqc.org.uk

  4. November 2019Requires improvementstayed Requires improvement
    Safe: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  5. September 2018Requires improvementstayed Requires improvement
    Safe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. August 2017Requires improvementup from Inadequate
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  7. March 2017Inadequatedown from Requires improvement
    Safe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  8. June 2016Requires improvementup from Inadequate
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  9. February 2016Inadequatedown from Requires improvement
    Safe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  10. August 2015Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate

    Read this report on cqc.org.uk

  11. November 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  12. January 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  13. September 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  14. January 2011

    Registered with the Care Quality Commission on 18 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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