CQC report explained · a residential care home
What the CQC found at Mountfield House Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2022
Mountfield House Care Home is rated Requires Improvement; inspectors found safety risks and weak checks, although people received kind care and their medicines.
This was an unannounced, focused inspection on 10 August 2022. Inspectors looked only at Safe and Well-led, including infection prevention and control. They spoke with six people, the provider and four staff, and checked care plans, medicine records and health and safety records.
The home was not always safe. Inspectors found unsecured wardrobes, unsafe window restrictors, concerns about hot water, fire exits, fire doors, legionella controls and damaged surfaces that could not be cleaned properly. Some issues were fixed during or shortly after the inspection, but the inspection found that people had been placed at risk.
People generally felt safe, received their medicines when needed and were supported by staff who were recruited and trained appropriately. Staff were described as well supported, and people and relatives were involved in decisions and activities.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three question ratings were not inspected and were carried forward from the previous inspection.
People felt safe
People told inspectors they felt safe living at the home and with the staff supporting them.
“People told us they felt safe living at the home and with the staff who supported them.” from the report
Medicines
Medicines were securely stored, records provided a clear audit trail and staff were trained and checked as competent.
“People told us they received their medicines when they needed them.” from the report
Staff support
Staff said they received regular supervision, training and support. Inspectors also found safe recruitment procedures.
“Staff were very positive about the support they received from the provider.” from the report
Activities and involvement
People were asked for their views and took part in meetings, menu planning and trips into the local community.
“People benefitted from regular trips out to the local community and beyond.” from the report
Environmental safety risks
seriousInspectors found several risks, including unsecured wardrobes, unsafe window restrictors, fire safety concerns, hot water risks, exposed wires and damaged fire doors.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Cleaning and infection control
needs fixingWorn varnish, damaged flooring and damaged bathroom tiles meant some surfaces could not be cleaned effectively. The provider later said repairs had been made.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises.” from the report
Weak quality checks
seriousThe provider’s audits did not identify the safety, fire, legionella and infection control problems found by inspectors.
“The provider's audits and monitoring systems were not effective in identifying the issues we found at this inspection.” from the report
- 01Have all the fire safety problems been fixed, including the damaged door closures, the updated fire risk assessment and the clear emergency exit route?
- 02How are hot water temperatures now checked and recorded, and how often are unused water outlets flushed and shower heads descaled?
- 03Have all wardrobes been secured, and have the window restrictors and first-floor balustrade been made safe?
- 04What new audits or checks are now in place to make sure environmental and infection control problems are found promptly?
- 05What evidence can you show that the action plan requested by CQC has been completed and that the improvements are being maintained?
This was a focused inspection of Safe and Well-led, including infection prevention and control under Safe; the other ratings carried over from the previous inspection. This explanation was written from the published report of 23 September 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.
What inspectors found, March 2020
Rated Good; inspectors found safe, kind and personalised care, with clear improvements since the previous Requires Improvement rating.
This was an unannounced follow-up inspection after the previous inspection found two breaches and rated the home Requires Improvement. One inspector spoke with people, staff and the manager, and checked care records, medicines records, complaints, health and safety records, quality checks and one recruitment record.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, staff were kind, people's choices were respected, and their health, food, activities and communication needs were supported.
The inspectors found improvements in care planning, risk assessments, medicines monitoring and management oversight. The previous breaches had been addressed, and the provider was no longer in breach of regulations.
Improved safety oversight
The home had improved how it recorded and reviewed incidents. Managers used monthly checks to identify patterns and reduce the chance of harm happening again.
“The registered manager now completed a monthly oversight report to review all incidents and accidents and ensured action was taken to reduce the risk of future harm.” from the report
Kind and respectful care
People said staff were kind, patient and respectful. Inspectors observed care that was unhurried and supported people's choices.
“We observed interactions between people and staff and saw staff were kind and unhurried as they provided care and support.” from the report
Personal choices respected
The home had corrected the previous problem with people's preferred getting-up times. Staff recorded and checked whether people were offered the times they wanted.
“Improvements had been made at this inspection, people's choices were now respected and the provider was no longer in breach of regulation 9.” from the report
Stronger management systems
The provider had increased the frequency of audits and introduced wider checks on incidents, care plans, risks, medicines and safety.
“The registered manager, who was also the provider, had made significant improvements to their governance and oversight systems and processes.” from the report
Further decoration needed
minorAlthough refurbishment had been completed and the environment met people's needs, the manager said more decoration was still needed throughout the home.
“However, the registered manager acknowledged further work was required throughout the home in terms of decoration.” from the report
- 01How do you check that each person's preferred time to get up is still being followed?
- 02What recent audits have you completed for medicines, care plans and risk assessments, and what did they show?
- 03What decoration or other environmental work is still planned, and when will it be completed?
- 04How do you provide meaningful activities for people who rely on staff for stimulation?
- 05How often do you review each person's end of life wishes with them and their family?
This was an unannounced follow-up inspection covering all five CQC questions; the inspector spoke with three people and two care staff and reviewed selected care, medicines, complaints, safety, quality and recruitment records. This explanation was written from the published report of 10 March 2020 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 Mountfield House Care Home
5 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- September 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2020Goodup from Requires improvementSafe: GoodWell-led: Good
- February 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- May 2011
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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