CQC report explained · a nursing home
What the CQC found at Scissett Mount
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks were not fully assessed or recorded. Inspectors also found medicines recording problems, incomplete medicine instructions and some people without accessible call bells.
- Effective?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management checks and audits did not always reflect the problems found or respond quickly enough. Oversight of maintenance and some care records was not reliable.
What inspectors found, March 2024
Scissett Mount rated Requires Improvement; inspectors found unsafe gaps in risk and medicines records, and weak oversight, despite caring staff and positive feedback.
This was a focused inspection after concerns about medicines. Inspectors visited on 9 and 18 January 2024. They spoke with people, relatives, staff and a healthcare professional, and checked medicines, parts of six care plans and management records.
The home was not always safe. Some risks were not fully recorded, some people did not have accessible call bells, and medicines records and instructions were not always reliable. Inspectors also found gaps in checks of equipment, water temperatures and emergency plans.
People and relatives said they felt safe. Staffing levels were sufficient, staff were recruited with the right checks, and medicines were usually given safely and respectfully. However, audits and management checks did not always identify or deal with problems quickly enough.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other areas were not inspected in this visit, so their previous ratings were carried forward.
People felt safe
People and relatives consistently said they felt protected from abuse. Safeguarding concerns were recorded and followed up.
“People and relatives consistently told us the service protected people from abuse.” from the report
Enough staff
Inspectors found enough staff to meet people's needs. People said waits for help were relatively short and manageable.
“Sufficient numbers of staff were in place to meet people's needs.” from the report
Respectful medicines support
Although medicines records had important gaps, staff gave medicines safely and respectfully, and their competence had been checked.
“Staff administered people's medicines in a safe and respectful way.” from the report
Positive relationships
People, relatives and staff gave positive feedback about the management team and opportunities to share views.
“Opportunities were provided to people, relatives and staff to be engaged and involved in the running of the home.” from the report
Partnership working
Weekly clinical meetings helped staff discuss changing needs and medicine matters with a GP. Community activities were also positively received.
“This was a well-run meeting which focused on people's changing needs and any related medication matters.” from the report
Risk records were incomplete
seriousSome people's risks were not recorded in enough detail, including choking, thickened drinks and dietary risks. Some people also did not have accessible call bells.
“Risks to people were not always identified and written into care records.” from the report
Medicine records were not always reliable
seriousTwo medicines were signed for on the wrong day. Information about one as-required medicine and the timing of another medicine was not sufficient.
“There was insufficient information in the PRN protocol about the care needs of a person and administration of their 'when required' medicine, which put them at risk of harm.” from the report
Management checks missed problems
needs fixingDaily walkarounds were not recorded for about six weeks. Audits gave high scores that did not match gaps found in care and capacity records.
“This meant we were not sufficiently assured of the effectiveness of governance checks.” from the report
Maintenance oversight was weak
seriousThe electrical wiring certificate had expired, hot water checks had not been done for several months, and emergency evacuation plans were out of date when the inspection began.
“There was insufficient oversight of maintenance checks.” from the report
Some mental capacity records were missing
needs fixingStaff supported people within the principles of the Mental Capacity Act, but assessments were absent for some people. The home said these records were due to be updated.
“Whilst people were offered choices and staff were able to identify whether people had capacity or otherwise, there was an absence of mental capacity assessments to support this for some people.” from the report
- 01What has been done to make sure every person has a complete, up-to-date risk assessment, including for falls, choking, eating and drinking, and behaviour?
- 02How are medicines records now checked to prevent wrong-day signatures and to make sure as-required medicine instructions are complete?
- 03How do you make sure call bells and sensor mats are accessible and working for each person who needs them?
- 04Who now completes the daily walkaround when the home manager is absent, and how is this checked?
- 05Have all mental capacity assessments, emergency evacuation plans and maintenance checks been updated, and how often are they reviewed?
This was a focused inspection of Safe and Well-led following concerns about medicines; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 March 2024 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 2023
Scissett Mount was rated Good overall; inspectors found safe staffing and improving leadership, but medicines records needed improvement.
This was an unannounced focused inspection on 22 February 2023. Inspectors looked at Safe and Well-led because concerns had been raised about medicines, staffing, training and moving people safely. They spoke with people living in the home, relatives and staff, and reviewed care records, rotas and other documents.
The overall rating was Good. Safe was rated Requires Improvement because medicine records were incomplete, fridge temperature checks were not always safe and some risks were not recorded properly. The home took immediate action, including introducing medicine audits and daily stock checks after the inspection.
People said they felt safe and received their medicines as prescribed. Inspectors found enough safely recruited staff, good infection control and appropriate safeguarding arrangements. Well-led was rated Good, with evidence of stronger oversight, open communication and action taken in response to concerns.
This was not a full inspection of all five areas. The ratings for Effective, Caring and Responsive were carried forward from the previous inspection. The previous overall rating was Good on 6 February 2021.
Staffing and safeguarding
Inspectors found enough staff and safe recruitment practices. People felt safe, and staff understood how to recognise and report abuse.
“There were sufficient numbers of safely recruited staff.” from the report
Infection control
The home was clean and hygienic. Inspectors found regular cleaning and staff who understood infection control procedures.
“High standards of infection control were maintained at this service as regular cleaning was taking place, which was found to be effective.” from the report
Improving leadership
The home manager was open about the problems found and had begun making changes. Inspectors saw stronger oversight and examples of learning from mistakes.
“The culture within the home was improving under new leadership.” from the report
Listening to feedback
People, relatives and staff were involved through meetings and surveys. Inspectors saw that feedback had led to action.
“Meeting minutes were detailed and demonstrated an open culture where voices were being heard.” from the report
Incomplete medicine records
seriousSome medicine records did not show where patches were applied or why medicines had been stopped. Two medicine records also lacked photographs to help prevent errors.
“Medicine records were not always fully completed. For example, a transdermal patch had been administered, but there was no record of where the patch had been administered to avoid skin irritation.” from the report
Medicine fridge temperature
seriousOne medicine fridge was recorded at 9.5 degrees Celsius, above the 8 degrees Celsius stated in the report for refrigerated medicines. The deputy manager acted immediately.
“One fridge temperature recorded 9.5 degrees Celsius, which was over the 8 degrees Celsius refrigerated medicines should be stored at.” from the report
Gaps in risk assessments
needs fixingSome risks were not recorded in people's risk assessments, including behaviour-related incidents and the use of a helmet to reduce injury from falls. The home manager acted immediately.
“One person did not have a risk assessment for incidents relating to behaviour.” from the report
- 01What changes have been made to medicine records, and how do you check that staff record patches, stopped medicines and each person's identity correctly?
- 02How are medicine fridge temperatures checked each day, and what happens if a temperature is too high?
- 03What risk assessments have been updated since the inspection, including risks relating to behaviour and falls?
- 04How do the new monthly medicine audits and daily stock checks work, and what have they found?
- 05How do you make sure people's views and relatives' feedback lead to action?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected and their ratings were carried forward from the previous inspection. This explanation was written from the published report of 25 March 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.
Every inspection of Scissett Mount
3 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- March 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2023Goodstayed GoodSafe: Requires improvementWell-led: Good
- February 2021GoodSafe: GoodWell-led: Good
- May 2019
Registered with the Care Quality Commission on 30 May 2019.
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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