CQC report explained · a residential care home
What the CQC found at Mountside Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found staff understood safeguarding, risk assessments were mostly clear and up to date, medicines were generally managed safely, and staffing levels met people's needs. They also noted some medicine recording errors and family concerns about medicines that were being investigated.
- Effective?
- Good
- This question was not covered by this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not covered by this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- Care plans had improved and generally reflected people's needs, preferences and communication requirements. Inspectors found some inconsistent oral care, a care plan that needed updating and delays in responding to some complaints.
- Well-led?
- Requires improvement
- Management and quality monitoring had improved, but repeated medicine recording issues, inconsistent oral care checks and gaps in complaint handling meant the home was not always well led.
What inspectors found, November 2022
Rated Good; inspectors found safe, responsive care, but the home still needs to improve its leadership and follow-up systems.
This was an unannounced focused inspection over three visits. Inspectors spoke with people living in the home, relatives, staff and health and social care professionals. They observed care and reviewed care plans, medicines records, training records, rotas and management documents.
The home was rated Good overall. Safe and Responsive were rated Good. Inspectors found enough staff, safer recruitment, suitable risk assessments, safe medicines administration and improvements in personalised care. The home was clean and well maintained.
Well-led was rated Requires Improvement. Governance systems had improved, but some problems had happened more than once without being fully fixed. These included missing checks on handwritten medicines records, inconsistent oral care and delays in responding to some complaints.
The previous overall rating was Requires Improvement. The provider was no longer in breach of regulations at this inspection, and the overall rating improved to Good. However, the inspection only looked at Safe, Responsive and Well-led, so the other question ratings carried over from the previous comprehensive inspection.
Safeguarding
Staff knew how to recognise and report abuse. Safeguarding records showed that concerns were reported and investigations were supported.
“Staff had a good understanding of safeguarding and knew how to recognise and report signs of abuse and who to report to.” from the report
Risk management
Risk assessments were mostly up to date and gave staff information about risks such as falls, poor nutrition and choking. The home also recorded learning after incidents.
“Risk assessments were clear, comprehensive and the majority were up to date.” from the report
Staffing and recruitment
Inspectors found enough staff during the visits, and recruitment checks were completed before new staff started.
“There were enough staff to support people safely during the inspection visits.” from the report
Personalised care
Care planning had improved and included people's physical, social and mental health needs. People said they were involved in decisions about their care.
“The care plans contained up to date information to guide staff on how to support people with their assessed needs.” from the report
Communication and activities
Staff recorded how people preferred to communicate and supported people with aids, large print and other communication methods. People could take part in group or individual activities.
“Peoples' communication needs were assessed, and care plans documented people's preferred names, how they communicate and what assistance they needed from staff.” from the report
Handwritten medicines records
needs fixingAudits had found that handwritten medicine entries did not always have the required checks by two staff members. The same issue happened again, so the action taken had not fully solved the problem.
“The actions taken had not completely addressed the issue as the errors had occurred again.” from the report
Oral care
needs fixingSome people did not have toothpaste and had dry toothbrushes. Inspectors said oral care support was not consistent for everyone, and this issue had also been identified at the previous two inspections.
“Oral health was an area identified on previous two inspections and whilst we saw that care plans included oral care and guidance, there were some people who had not received support with oral health.” from the report
Complaints and communication
needs fixingSome complaints sent by email had not received a response. Clinical concerns were not always passed promptly to the registered manager, which caused delays and left one family feeling ignored.
“There were gaps in the complaint procedures followed.” from the report
- 01How do you make sure two staff check and sign every handwritten medicine entry and verbal medicine order?
- 02How do you check that every person receives the oral care recorded in their care plan?
- 03Who receives complaints and clinical concerns when the deputy manager is not working?
- 04How quickly will my complaint be acknowledged and answered?
- 05Which ratings were carried over from the previous comprehensive inspection rather than assessed during this visit?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not looked at and their previous ratings carried over. This explanation was written from the published report of 30 November 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, November 2021
Rated Requires Improvement and no longer in special measures; inspectors found progress but continued safety, care-planning and governance breaches.
This was an unannounced focused inspection over three days in October 2021. Inspectors spoke with people, relatives, staff and professionals. They observed care, checked six care records, medicines records, staff files, training records and management documents.
The home had made improvements since its previous Inadequate rating. Infection control, recruitment, training, activities, complaints handling and some medicines records had improved. People told inspectors they felt safe, were well cared for and enjoyed living there.
Important problems remained. Records did not always show changes in people's health, falls, wounds, weight loss or daily care. Staff did not always manage risks, medicines or safeguarding incidents safely. The overall rating changed from Inadequate to Requires Improvement, but four regulations were still breached.
People felt safe
People told inspectors that staff looked after them and that they felt safe. Staff were described as kind and respectful.
“This is my home, I feel I am safe and they are good to me,” from the report
Infection control
Inspectors found that COVID-19 precautions, testing, personal protective equipment, cleaning and visiting arrangements were in place.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staffing and training
There were enough staff during the inspection, call bells were answered promptly and essential training had progressed. Recruitment checks had also improved.
“There were enough staff on shift at the service to support people.” from the report
Complaints were investigated
The home had a complaints policy and kept a complaints log. Inspectors found that complaints were investigated and answered promptly.
“Complaints were investigated and responded to in a timely manner.” from the report
Activities and contact
Most people could join group or one-to-one activities. People were also supported to contact relatives using phones, Skype and email.
“Most people were supported to participate in social and leisure interests and enjoyed one to one and group activities provided by the service.” from the report
Safeguarding was not always followed
seriousStaff did not follow the home's procedure after an alleged abuse incident. Reporting was delayed, information was missing and some injuries were not reported or recorded properly.
“The provider had not ensured service users were protected from abuse and improper treatment.” from the report
Risks and incidents were not managed consistently
seriousCare plans and risk assessments did not always reflect falls, wounds, mobility changes or weight loss. Inspectors found missed opportunities to learn from repeated falls and prevent further harm.
“The provider had not ensured the safety of people by assessing the risks to their health and safety and doing all that is practicable to mitigate any such risks.” from the report
Controlled medicines
seriousControlled medicine audits had stopped for three months. Errors and stock discrepancies were not always acted on immediately, so the provider could not be sure these medicines were managed safely.
“The provider had not ensured the proper and safe management of medicines.” from the report
Care plans were not personal enough
seriousSome plans were generic or out of date. They did not always guide staff about choking, oral care, dementia-related night-time behaviour or pain.
“The provider has not ensured that people received appropriate care that met their individual needs and reflected their preferences.” from the report
Weak records and audits
seriousGovernance systems had improved but were not consistently used. Daily records, food and fluid charts, wound records, incident records and some audits were incomplete.
“The provider had failed to establish and operate effective governance systems to assess, monitor and mitigate the risks to people's health, safety and welfare.” from the report
- 01How are you now recording and reviewing falls, wounds, skin injuries and changes in mobility?
- 02What checks are now in place for controlled medicines, and how are errors or stock differences dealt with?
- 03How do you make sure choking guidance, oral care, pain relief and dementia support are included in each person's care plan?
- 04How are weight loss and food and fluid intake monitored, and what happens when someone does not eat or drink enough?
- 05What action has been completed in response to the four breached regulations, and what evidence can you show of sustained improvement?
This was a focused inspection of Safe, Responsive and Well-led, with infection control also reviewed; the other question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 5 November 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 Mountside Care Home
8 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Requires improvementup from InadequateSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2021Inadequatedown from Requires improvementSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- December 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2019Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Requires improvement
- August 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2014
Report published without a new overall rating.
- September 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 7 December 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 £1,000 to £1,400 a week. 13 can care for a couple. 10 years' experience on average.
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