CQC report explained · a nursing home
What the CQC found at Mountfitchet House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- There were enough staff, recruitment checks were completed, medicines were managed safely and infection control was effective. Some risk assessments were not updated when people's needs changed, which could have given staff contradictory guidance.
- Effective?
- Requires improvement
- Inspectors observed unsafe moving and positioning practices and found that care did not always follow care-plan guidance. Induction records did not always show that new care staff had completed the required learning.
- Caring?
- Good
- People and relatives described staff as kind, friendly and respectful. Staff offered choices and involved people and relatives in care decisions, although one interaction did not protect a person's dignity.
- Responsive?
- Good
- People and relatives were involved in care planning and the home responded to complaints. Feedback about activities was mixed, with limited trips and some concerns about the range of activities.
- Well-led?
- Good
- People, relatives and staff spoke positively about the management and culture. The home used audits, meetings and feedback to identify improvements and worked with health and social care professionals.
What inspectors found, August 2023
Rated Good overall; inspectors found kind, safe care, but effectiveness Requires Improvement because some care and moving practices were not consistently safe.
This was an unannounced inspection on 21 June 2023. Inspectors spoke with people, relatives, staff and healthcare professionals. They observed care and reviewed care plans, medicines records, staff files and service records.
The home was rated Good overall. Safe, caring, responsive and well-led were rated Good. Medicines, staffing, recruitment, infection control and complaints were managed well. People described staff as kind and respectful.
Effective was rated Requires Improvement. Inspectors saw unsafe moving and positioning, care that did not always follow people's plans and gaps in induction records for new care staff. Risk assessments, food and drink records and personalised life-history information also needed updating.
The overall rating was lower than the previous Outstanding rating, published in September 2018. The provider acted promptly on the issues raised during the inspection, including arranging retraining, supervision and updates to records. CQC said it will continue to monitor information about the home.
Kind staff
People and relatives spoke positively about staff. Inspectors observed staff taking time to listen and respond kindly.
“We observed staff speaking to people in a kind and caring way, taking their time, and listening to what people wanted.” from the report
Safe medicines
Staff were trained and assessed as competent to administer medicines. Records and stock checks were accurate.
“People received their medicines as prescribed. Staff had received medicines training and the provider had assessed their competency to ensure they understood how to support people safely.” from the report
Enough staff
Inspectors found enough staff to meet people's needs, and staff responded promptly when people asked for help.
“There were enough staff available to support people's needs.” from the report
Good leadership
The management team was visible and approachable. The home used audits, feedback and partnerships with other professionals to improve care.
“The provider had systems in place to monitor the safety and quality of people's care.” from the report
Involvement in care
People and relatives were involved in planning and reviewing care. Care plans recorded preferences and daily routines.
“People and their relatives were involved in planning and reviewing their care.” from the report
Unsafe moving support
seriousInspectors saw staff supporting people to stand in a way that could cause injury. The provider arranged immediate discussion, observation and retraining.
“This type of support is not safe for the person and places them at risk of sustaining an injury.” from the report
Care did not always follow plans
seriousOne person's documented continence preferences were not followed during the inspection. Inspectors said this affected the person's dignity and independence.
“People's care was not always delivered in line with their care plans and did not always follow best practice.” from the report
Induction records
needs fixingFor some staff new to care, records did not clearly show how they had gained the required knowledge and skills. The provider said it would review the induction documents.
“It was not always clear whether they had been supported to complete the Care Certificate.” from the report
Risk records
needs fixingSome risk assessments were not updated when people's mobility needs changed. This could leave staff with conflicting instructions, although staff knew people's current needs during the inspection.
“This meant staff may have contradictory guidance about how to support people safely.” from the report
Food and activities
minorFeedback about meals, snacks and activities was mixed. Some records of snacks and drinks were incomplete, and the minibus was not working, limiting trips out.
“The provider told us they were aware of people's concerns and had already responded to people's feedback by asking for suggestions and trialling new, more tailored activities throughout the week.” from the report
- 01What checks have been completed to make sure all staff use safe moving and positioning techniques?
- 02How do you now make sure care is delivered in line with each person's care plan and preferences?
- 03How do you record and monitor induction and Care Certificate progress for staff who are new to care?
- 04Have all risk assessments been updated when people's mobility or other needs change?
- 05Has the minibus been repaired, and what activities and trips are now available?
This was an unannounced inspection covering all five key questions, including infection prevention and control; the report says the overall rating changed from Outstanding at the previous inspection to Good. This explanation was written from the published report of 31 August 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, January 2021
Mountfitchet House was inspected but not rated; inspectors found reassuring infection control arrangements during a targeted visit.
Inspectors visited on 12 January 2021. The visit was announced and focused only on infection prevention and control because of the CQC's response to coronavirus risks in care homes.
Inspectors found good practice. This included an infection prevention and control champion, clear signs about infection control, more frequent cleaning of high-touch areas and plans for a visitor pod.
They were assured that the home was managing visitors, social distancing, admissions, personal protective equipment, testing, hygiene and infection outbreaks safely. The home was inspected but not rated, so this report does not give an overall quality rating.
Infection control lead
The provider had given one staff member responsibility for infection control checks, protective equipment supplies and keeping guidance up to date.
“The provider had assigned one member of staff the role of infection prevention and control champion for the service.” from the report
Clear information
Signs around the home explained the outbreak and gave staff and visitors infection prevention and control information.
“There was clear signage at the entrance to the service and throughout the building alerting staff and visitors to the outbreak” from the report
More frequent cleaning
Cleaning had been increased, with particular attention to areas people touch often.
“The provider had increased the frequency of cleaning throughout the service, with particular emphasis on high touch areas such as door handles and light switches” from the report
Inspectors raised no specific concerns in this report.
- 01How often are infection prevention and control audits now completed, and what happens when they identify a problem?
- 02How do you check that supplies of personal protective equipment remain sufficient and that staff use it safely?
- 03Is the visitor pod that was being built at the time of inspection now complete and available?
- 04How often are high-touch areas such as door handles and light switches cleaned now?
- 05How are people using the service and staff tested, and how are any positive results managed?
This was an announced, targeted inspection of infection prevention and control practices only; the service was inspected but not rated and the other care questions were not covered. This explanation was written from the published report of 29 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 Mountfitchet House
2 rated inspections over 5 years: the service has slipped, from Outstanding to Good.
- August 2023Goodcurrent ratingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- January 2021Inspected but not ratedSafe: Inspected but not rated
- November 2018OutstandingSafe: GoodEffective: GoodCaring: OutstandingResponsive: OutstandingWell-led: Outstanding
- February 2016
Registered with the Care Quality Commission on 25 February 2016.
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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