CQC report explained · a residential care home
What the CQC found at Mountjoy Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2019
Mountjoy Road was rated Good overall; inspectors found safe, kind and person-centred care, with some care records needing improvement.
This was a planned inspection on 26 March 2019. One inspector visited the home, spoke with people, relatives, staff and the manager, observed care, and checked care records, medicines records and quality checks.
The home provided accommodation and personal care for up to eight people with learning disabilities and behaviours that may challenge. Seven people were living there during the inspection. Inspectors found people were safe, treated with kindness and involved in decisions about their care.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. The home had kept its Good overall rating from the previous inspection in August 2016.
People felt safe
People and relatives said staff treated people well and people felt safe. Safeguarding concerns had been reported correctly and action had been taken to reduce the chance of recurrence.
“People were safe and protected from avoidable harm. Legal requirements were met.” from the report
Kind and respectful care
Inspectors saw positive relationships between staff and people. Staff supported privacy, dignity, communication and independence.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised support
Staff knew people well and care plans reflected their needs and preferences. People were supported to take part in everyday tasks and community activities.
“People received personalised support from staff who knew them well.” from the report
Good leadership
People, relatives and staff were positive about the management. Audits were used to identify actions and support improvements.
“The service was consistently well-led. People felt able to raise any concerns with the registered manager and were confident they would be addressed.” from the report
End-of-life records
needs fixingSome people's records about their preferred end-of-life wishes lacked detail or were not completed. The manager said this would be looked into.
“However, some lacked detail or were not completed in some people's files.” from the report
Staff file audits
needs fixingThe staff file audit had not been completed for several years. Inspectors found the files checked were up to date, and the manager said all staff files would be audited.
“However, the staff file audit had not been completed for a few years.” from the report
Delayed survey information
minorThe latest surveys had not reached the home from head office at first. The manager arranged for them to be brought to the home, and the surveys were positive.
“The last surveys received in October 2018 had not been received from head office” from the report
- 01Have all residents' end-of-life wishes now been discussed, recorded and reviewed?
- 02Have staff file audits now been completed for every member of staff?
- 03How are survey results received, recorded and acted on by the home?
- 04How will my relative be supported to make choices and develop independence?
- 05How will the home involve my relative and our family in reviewing their care plan?
This was a planned inspection covering all five key questions and reassessing the overall quality of the home. This explanation was written from the published report of 11 April 2019 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, October 2016
Rated Good; inspectors found safe, kind and personalised care, with improvements needed in quality monitoring and some legal safeguards.
This was an announced, comprehensive inspection on 10 August 2016. One inspector spoke with four people living at the home and staff, reviewed care and staff records, checked medicines and safety systems, observed care, and looked around the premises.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable training, respectful care, support for activities and family relationships, and a positive atmosphere.
There were some areas to improve. Quality checks did not clearly lead to action plans or feedback. Some support plans were not as person-centred as they could be, and most legal safeguards applications were still awaiting an outcome. The home was not found to be in breach of regulations.
Safe medicines
Medicines were obtained in time, stored safely, given as prescribed and recorded correctly. Some people were also supported to manage their own medicines safely.
“We saw that medicines were obtained in a timely way so that people did not run out of them, that they were stored safely, and that medicines were administered on time, recorded correctly and disposed of appropriately.” from the report
Kind and respectful care
Staff knew people well and treated them with compassion. Inspectors saw that privacy, dignity and independence were respected.
“People's wellbeing, privacy, dignity and independence were monitored and respected and staff worked to maintain these wherever possible.” from the report
Choice and activities
People were supported to choose their food, routines, activities and social life. The home helped people stay connected with family and the local community.
“People had choice in respect of the foods they ate, who they socialised with, when they rose from bed or went to bed, what they did for entertainment and occupation” from the report
Suitable staff and premises
Staff had training, supervision and appraisals. The home was comfortable, well furnished and maintained safely.
“People were cared for and supported by qualified and competent staff that were regularly supervised and received appraisal of their performance.” from the report
Quality checks did not lead clearly to improvements
needs fixingThe home carried out audits and surveys, but inspectors could not see how the information was used to create improvement plans or how feedback was given to people who contributed.
“We saw no evidence that quality monitoring information was used to generate action plans for improvement of the service or that feedback was given to people that contributed to the satisfaction surveys.” from the report
Support plans could be more personal
minorThe plans reflected people's needs, but they were written in the third person rather than being as person-centred as they could be.
“Support plans were not as person-centred as they might be as they were written in the 'third person', but they were reflective of people's individual needs.” from the report
Periods of lone working
needs fixingThere were times when one worker was alone, including during sleep-in duties and when staff left to collect people from day care. The provider had assessed the risks and inspectors still rated the service safe.
“The night times also saw one staff member lone working (on-call doing sleep-in duty), which meant there were times when staff and people that used the service were more vulnerable.” from the report
Safeguards awaiting decisions
needs fixingApplications for legal safeguards had been submitted for all six people, but only one outcome had been received by the inspection. Ask what happened after the inspection.
“We found that for all six people that used the service a DoLS application had recently been submitted (June 2016) but only one outcome had been received by the registered provider.” from the report
- 01What action plans have been introduced following the inspectors' recommendation about quality monitoring?
- 02How do you now share feedback with people, relatives and professionals who complete surveys?
- 03What were the outcomes of the legal safeguards applications submitted for all six people?
- 04How do you keep people safe and supported when one staff member is working alone?
- 05How have support plans been made more person-centred since this inspection?
This was a comprehensive inspection covering all five key questions, based on discussions with people and staff, records, observations, medicines and safety checks, and a premises visit. This explanation was written from the published report of 4 October 2016 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 Mountjoy Road
2 rated inspections over 3 years: the service has held its Good rating throughout.
- April 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
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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Most charge £980 to £1,260 a week. 86 can care for a couple. 11 years' experience on average.
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