CQC report explained · a residential care home
What the CQC found at Mountfield
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2021
Rated Requires Improvement; inspectors found better care and leadership, but records and end-of-life planning still needed work, and the home had left special measures.
This was an unannounced follow-up inspection over three visits in April and May 2021. Inspectors observed the home and care, reviewed records and medicines, spoke with staff and one person, and collected views from nine relatives and a family friend.
The home had improved since its previous Inadequate rating. Inspectors found cleaner premises, better risk checks, safer medicine systems, improved staff training, and kind care. People were supported to make choices, and relatives reported recent improvements in communication.
Further work was still needed. Some care records contained contradictory or outdated information. End-of-life plans did not always record people's wishes. Communication with relatives was mixed, and some security and medicine information needed attention.
The overall rating was Requires Improvement. Safe, responsive and well-led were rated Requires Improvement. Effective and caring were rated Good. The home was no longer rated Inadequate and was no longer in Special Measures.
Clean and improved infection control
Inspectors found the premises very clean and saw that infection control arrangements had improved. Staff were using personal protective equipment and other measures appropriately.
“We observed the home to be very clean, and that changes had been made to the deployment and oversight of domestic staff's work.” from the report
Kind and respectful staff
Staff treated people with dignity, offered choices and responded quickly when people were distressed. Relatives also described recent improvements in care and involvement.
“We observed staff to be kind, caring and empathetic towards people, responding to those in distress quickly and reassuringly.” from the report
Improved staff skills and support
Staff had received more training, regular supervision and work-based observations. Staff said they felt more confident supporting people with complex needs.
“Staff reported training and support had improved.” from the report
Better food and drink monitoring
The home had introduced comprehensive nutrition and hydration records. Staff acted when monitoring showed a possible risk to a person's wellbeing.
“Since our last inspection, all people had a hydration and nutrition record which had been completed comprehensively, with person centred and realistic targets.” from the report
Contradictory care records
needs fixingSome care records still contained outdated or conflicting instructions. Inspectors said this could cause confusion and could put a person at risk of poor skin care.
“However, some records still contained out of date or minor contradictions in information, that had not been removed as part of the improvement process.” from the report
End-of-life wishes not fully recorded
needs fixingEnd-of-life plans did not always record what mattered to people and their relatives, including funeral wishes. The manager started work on a new plan after the inspection.
“For example, end of life care plans did not detail the wishes of the person regarding their funeral arrangements, or what would be important to them at this time.” from the report
Mixed communication with families
needs fixingSome relatives felt communication had improved, but others felt updates were slow and were unclear about management changes. The manager changed the newsletter and planned more direct contact.
“Many relatives were still unclear who the manager or management team was and wanted more information on changes made to progress the service since the last inspection.” from the report
Security and medicine details
needs fixingAn external gate had been left unlocked, and information about applying a skin barrier cream was unclear. The management team acted on these issues during the inspection.
“However, during our inspection we found a padlocked external gate had been left unlocked and found out of date food in a fridge used in the visitor's room.” from the report
- 01How do you now check that care records contain no contradictory or outdated instructions?
- 02What has changed in the new end-of-life care plan, and how will you record each person's wishes?
- 03How are families told about management changes and updates to their relative's care?
- 04How do you check that external gates are secure and that other premises risks are dealt with promptly?
- 05How do staff receive clear instructions about applying topical creams and recording people's medicine preferences?
This was an unannounced follow-up inspection covering all five key questions and checking action taken after the previous Inadequate inspection and Warning Notice. This explanation was written from the published report of 23 September 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, January 2021
Rated Inadequate and placed in special measures; inspectors found people at risk of harm, unsafe infection control and poor management oversight.
The inspection took place without notice on 14 and 29 October 2020. Inspectors observed the home, spoke with people, relatives and staff, and checked care records, medicines, the building and safety systems.
Inspectors found serious problems with risk assessments, pressure care, falls, infection control, fire safety, equipment and secure exits. Care plans were often incomplete or inaccurate. People were not always involved in planning their care, including end of life care, cultural needs and contact with relatives.
Some staff interactions were kind, and food and staffing arrangements had some positive features. However, systems for complaints, incidents, feedback and quality checks were not working well. The home was rated Inadequate overall, with Safe and Well-led also Inadequate, and the other three areas Requires Improvement.
The provider took action on some immediate risks after the visits. CQC required an action plan, will monitor progress and plans to re-inspect. The home was placed in special measures, meaning CQC will check whether significant improvements are made.
Kind individual interactions
Inspectors saw staff being supportive and attentive when people were distressed. Some relatives also described staff as committed and lovely.
“We observed supportive interactions and staff were attentive to people if they were showing distress.” from the report
Food and dietary choices
People's individual dietary requirements were met. People and relatives generally described the food positively, and mealtimes were flexible.
“People and relatives told us the food was of good quality.” from the report
Safe recruitment
The home followed recruitment checks, including checking staff character, to help identify possible risks before employment.
“Processes had been followed, including appropriate character checks, to help ensure staff were recruited safely and potential risks identified.” from the report
Action after inspection
The provider responded to the most immediate concerns and took steps to improve environmental safety and staff understanding of infection control.
“Following the concerns raised at our inspection the provider responded promptly to address the most immediate and pressing concerns.” from the report
Poor infection control
seriousCOVID-19 risks were not properly assessed, and staff did not always follow infection control guidance. Waste, bins and sluice rooms were not managed safely.
“Effective actions had not been taken to ensure infection control risks had been assessed, controlled or prevented.” from the report
Unsafe premises and equipment
seriousThe building and equipment were not consistently clean, secure or maintained. Inspectors found exposed wires, overdue servicing and a restricted fire exit.
“The premises and equipment were not clean, secure, properly maintained, or suitable for the purpose for which they were being used.” from the report
Incomplete person-centred care
seriousAssessments and care plans did not give staff enough accurate information. People's end of life, cultural, religious and family contact needs were not always planned for.
“People's care needs had not been met or planned for collaboratively.” from the report
Weak management systems
seriousAudits did not lead to timely action, and incidents were not used for learning. People, relatives and staff were not asked for feedback often enough.
“Quality monitoring systems were ineffective in monitoring and improving the quality of the service.” from the report
- 01What changes have been made to assess and manage pressure sore, weight loss and falls risks?
- 02How are infection control, waste disposal and sluice room practices now checked each day?
- 03How do you make sure care plans include end of life, cultural, religious and family contact needs?
- 04What evidence can you show that audits, complaints and incidents now lead to action and learning?
- 05How are topical creams recorded and checked to confirm they are given as prescribed?
This was an unannounced inspection of all five key questions, including the care provided, premises, equipment and infection prevention measures. This explanation was written from the published report of 7 January 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.
Every inspection of Mountfield
2 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- September 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2021InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2014
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- April 2011
Registered with the Care Quality Commission on 25 April 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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13 live-in carers within about an hour of Norfolk
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 £990 to £1,120 a week. 9 can care for a couple. 14 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.