Mont Calm Residential Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified two breaches of the legal regulation. The risks associated with people’s care were not always being managed in a safe way. There was not sufficiently qualified and competent staff to support people in a safe way and medicines were not always managed in a safe way. People at times were being administered ‘as and when’ medicines when it may not have been necessary. We found concerns around the management of people's incidents. Staff were not always following good infection control. The environment was not always set up in a safe way. We found concerns around the staff being suitably trained and competent.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although relatives told us they were being contacted when an incident occurred, we found they were not always provided with accurate information on how the incident occurred as staff were not always recording enough detailed information. People were not supported in a safe way when incidents occurred, and the lack of details records meant that opportunities to learn from incidents and prevent recurrence were missed.

There was a mixed response from staff on when they should record incidents. One told us they would not always record a person’s high level of anxiety. They said it would depend on the level of distress that was observed and who else was impacted. One member of staff gave us an account of an incident on the day of our visit. However, this was not reflective of what we observed. The incident form they completed also lacked detail around the incident. This meant the registered manager was not aware of all incidents occurring at the service to ensure things were put in place to reduce further risks.

The registered manager reviewed themes and trends of falls that occurred in the service. However, there was a lack of evidence that incidents were always investigated in a timely way to determine the cause and mitigate the risk of recurrence. For example, we saw 1 person had a large bruise on their face which occurred the day before our visit and was recorded as unwitnessed injury. A member of staff told us how this could have occurred, but they could not be certain. Aside from the senior staff seeking external health care for the person, at the time of our visit, no action had been taken to investigate the possible cause for the bruising. There was also no update in their care plan to include the mitigation of this risk.

Whilst some relatives said they were able to view the home before their loved ones moved in, there were people and relatives who told us they had not been included in decisions about moving to Mont Calm. Comments included, “We were not given any other options, it was a very stressful situation. I wouldn’t have chosen Mont Calm” and “I would have preferred to see it beforehand, but the hospital needed the bed. I would have like more options but was told this was the only one available.” One person told us they felt people moved in whether or not the home could meet their needs. They said, “This is more of a nursing home. They take anyone to get the money.”

Staff told us they were told some information about people’s needs before they moved in. However, they told us this was limited to mainly the person’s mobility and nutritional needs. The registered manager told us they frequently admitted people straight from hospital. They told us in these incidences they would not speak with the person or the family about the person’s preferences around care. They said, “Because families resist, we are told not to contact families.” This meant they may not have all the appropriate information to determine whether they could safely meet the person’s needs.

Partners told us they were aware of the concerns with admissions from hospital where people and their loved ones have not always been consulted in decisions about which care setting they moved to. They told us the registered manager could communicate more effectively with people and their loved ones to establish more information about people’s needs before they moved in.

The registered manager completed pre-assessments before people moved in. However, these were not always person-centred and focused more on the person’s health needs. The majority of the pre-assessments were completed over the phone. There was a lack of evidence to demonstrate where people were in hospital, staff from the home visited them to gain a better understanding of their needs. There was also a lack of consideration of whether people moving in with high levels of anxiety could be triggered by other people already living at the home with similar anxieties.

People told us they felt safe, and the service and relatives fed back they felt their loved ones were safe. Comments included, “I haven’t found anybody nasty”, “Definitely feel safe, the staff give out the aura” and “Without a doubt safe and looked after.” Despite this, we found people were not always protected from the risk of abuse.

There was a mixed response from staff about their understanding of safeguarding. One told us safeguarding was to, “Help people, human rights, support people.” Whilst another told us they would look out for any signs of abuse and report this. However, we found staff were not always reporting safeguarding concerns.

During the visit we observed 1 person not being supported in a safe way when they had fallen. We observed a senior member of staff lifting a person from under the person’s armpits risking damage to the person’s skin and shoulder and injury to the member of staff. We have raised this to the local authority safeguarding team. We saw 1 person had a large bruise on their face, however no action had been taken to determine how this had been caused whether this was caused by a fall or another person or member of staff. We did observe that other people looked calm and relaxed in staff presence.

People were not always fully protected from the risk of abuse and neglect. Most safeguarding concerns had been investigated and raised with the local authority. However, the incident with the bruise found on the person had not been investigated appropriately or reported to the local authority until we raised this.

People and relatives felt risks were managed well. Comments included, “There is a risk I might fall, but there is always someone here if I need to get up and make sure I have someone behind me when I go somewhere” and “At home with dad she was really bad risk of falling. Since she has come here, she has only had two or three falls.” Despite this we found people were not always involved in the management of risks. Risks associated with people’s care were not always managed in a safe way.

Staff told us how they managed people’s risks including the risk of dehydration, malnutrition, skin pressure damage risk management and constipation. However, we found people’s care records that staff completed did not always reflect they understood people’s risks and there was a lack of recording of the monitoring of people’s individual risks.

The chairs in some of the communal rooms were low and we saw people struggle to stand up from them. There was an emergency lifting cushion that provided safe, dignified support for people. However, we observed when a person had fallen, staff did not use this equipment and instead drag lifted the person to assist them to stand. This placed them at risk of harm. We observed people were regularly supported to have drinks and people had their walking aids placed next to them by staff when they were sat in the lounge. Where people had pressure mattresses these were set to the correct weight of the person.

The provider failed to ensure risks associated with people’s care were always managed in a safe way. For example, 1 person had frequent seizures. The guidance in the care plan stated staff were to record the length of the seizure to determine whether emergency medicine was required. However, there was no guidance for staff on how they needed to support the person during a seizure. Staff were also not recording any detail of the seizures. Another person was required to be encouraged to elevate their legs due to a health condition. Although it was recorded in their care plan the person can refuse, staff were not routinely recording whether or not they were encouraging the person to do this. There was conflicting information in people’s care plans around the risk associated with their care. Where people were at high risk of constipation, staff were not routinely recording when they had opened their bowels. This placed people at further risk of becoming unwell. Risk assessments were at times contradictory and did not always reflect the most current needs. This meant staff may not provide the most appropriate safe care. Other areas of risk were managed well including when people were at risk of dehydration and malnutrition. People were weighed weekly and the registered manager regularly reviewed people’s fluid intake to ensure they were drinking sufficient amounts.

People and relatives told us they felt the home environment was safe, but they would like to see improvements in the home. Comments included, “New furnishing (are needed) and spruce up the building”, “The bathroom is a horrible, horrible room, freezing room. It’s my least favourite room.” Relatives raised with us concerns about the safety of the garden. One told us, “One concern is going out from the lounge and a little ramp walkway onto a path into the garden and its lethal particularly for elderly.”

Staff had concerns about safety of the environment and furnishings. Comments included, “If there is something blocking, we struggle, we have to move these things. Due to the building, it’s not adequately spaced”, “Due to the layout of the home, it’s hard to manoeuvre round with people” and “They (lounge chairs) are too low, they (people) can’t get out of them properly. I see my residents struggling to get out of them.”

People were at risk as the provider had failed to ensure the equipment in the building was safe. We observed the fire extinguishers safety checks were out of date, as were the items in the first aid box. The registered manager did address this straight away. The ‘grab’ folder that would be used in an emergency did not have accurate details around who lived in the home and lacked information on how many staff were required to support people. The registered manager resolved this on the day of the visit. There were people that smoked. However, there was no ashtray in the garden for them to dispose of their cigarettes which was a fire risk. We found the medicines room door was left unlocked despite a sign saying the door needed to be locked which meant there was a risk people other than staff could access the room.

The provider failed to ensure appropriate checks were undertaken to review the safety of the environment. Although there were daily checks of the maintenance of the environment, this was not always effective in identifying shortfalls. Monthly audits were being conducted, where actions were identified, these were not always being completed by the dates the provider set as required completion timeframe. For example, a review of the wiring at the home was completed in April 2024 and a quote for works was to be undertaken. However, there was no update to this. Hoist and sling checks were due in August 2024, yet this had not been undertaken at the time of the assessment, meaning there was potential for the equipment to be unsafe. There had been some recent works undertaken to the home including replacement of flooring, kitchen refurbishment and redecoration. Although it was recorded on the home business plan the laundry room was due to be moved from the basement between December to January 2025, there was nothing on the plan on what action the provider was going to take to address the poor state of the laundry room in the meantime.

People and relatives fed back there was always sufficient staff. Comments included, “Always seem to be enough staff”, “Yes enough, because they are there, as soon as you move, they are there with you” and “They are pretty good at answering the bell.” However, we found people did not benefit from a staff team that were adequately trained and skilled to provide safe and effective care. Staff lacked an understanding of how to always safely care for people they were supporting.

Staff we spoke with did not have a good understanding of dementia, modified diets or the principles of the mental capacity act. This meant there was a risk they would not provide safe or effective care. Staff fed back they would like to have more detailed dementia training. They said they would also like to attend training to understand better how to support people when they have high levels of anxiety. One told us, “I think in a dementia care home we need more training in challenging behaviour or dementia related training. I have completed my e-learning, but I think face to face would be better.” Staff did say however they thought there were enough staff on duty. One member of staff, “We get there quickly when people use their call bells.”

We observed staff at times were providing safe and effective care. We observed an unsafe moving and handling procedure. One person was required to have their food minced and moist, but staff were pureeing their meal. We did see there were sufficient staff at the home. When call bells were used, staff responded quickly. Where people in the communal areas got up to walk around the home, staff were quick to support them.

The provider failed to ensure staff had received all the training they required in relation to people’s care needs. One person had epilepsy, yet no staff had received epilepsy training. Another person was on a modified texture diet, yet no staff had received training on how to prepare this to the right consistency. There were multiple staff that had not received first aid or palliative care training. Where staff had received training and supervision, this had not been effective in ensuring good care. Given the majority of people living at the home were living with dementia, we found only basic dementia awareness training had been provided. The provider operated effective and safe recruitment practices when employing new staff. This included requesting and receiving references and checks with the disclosure and barring service (DBS).

People and relatives raised concerns about the cleanliness of the home. Comments included, “The only thing is cleanliness, there is a strong smell when you go in and my (family member) did smell as well” and “The smell (of urine) can be breathtaking” and “Very often it smells in (person’s) room.”

Although staff were able to tell us when they needed to use Personal Protective Equipment (PPE), staff also told us cleaning the home can be difficult due to the layout of the building. Comments from staff included, “Sometimes its smells of urine. Sometimes it’s bad and no (can’t get rid of the smell)” and “I try to clean everything good. Can be a struggle, everyday some rooms are very smelly.” Another told us the home is not cleaned effectively. The registered manager told us they were not aware of the smell of urine. They said they had recently changed some flooring in the communal areas and felt this had addressed the concern. They told us 1 person had a health condition that can be infectious and at times the person needed to be cared for in their own room only. However, we found this was not always followed.

The provider had failed to ensure good infection control practices (IPC) which placed people at risk. We identified the smell of urine when we arrived at the home, and this remained all day particularly in some people’s rooms. In the morning a commode in 1 person’s room was full and was still not cleaned at the point when we left several hours later. The laundry room was in the basement and was not set up to ensure good IPC. Dirty maintenance items had been left in there, mops were stored with the mop head down on the dirty floor. The sink area was degraded and stained and there were thick cobwebs underneath the open sink area. The bathroom on the ground floor was not clean and had exposed dusty pipes. All this increased the risks of infection spread and cross-contamination.

Although infection control audits were taking place, this was not effective in identifying the concerns we found. For example, an audit in July 2024 recorded there were no urine smells in the home. It stated that staff operate a ‘dirty/clean’ system in the laundry room, however there was no space in the laundry for them to do this. The audit concluded there were no actions required. Yet, we found this was not the case and there were multiple shortfalls in IPC in the home. Where people had a condition that could be infectious, staff were not ensuring the followed the guidance on this to prevent the spread of infections. Staff were not always keeping people in their rooms when required to do so.

People told us they received their medicines when needed. However, we found the management of medicines was not always undertaken in a safe way. We observed one of medicine rooms was very warm and the thermometer recorded the room temperature of 30 degrees Celsius. A member of staff told us the room should not be warmer than 25 degrees Celsius. This meant there was a risk effectiveness of the medicines being reduced. Staff were not always recording the placement of a medicine patch on a person which increased the risk of skin irritation, if it was placed on the same area.

Staff who had been trained to administer medicines told us they had been competency assessed to do so. The registered manager told us they tried not to use ‘as and when’ anti-psychotic medicine for people if not required. However, we found people were receiving ‘as and when required’ medicines including anti-psychotic medicines and constipation medicines when it was not clear whether it was required.

In the main people were receiving their medicines when required. However, there were elements to the management of medicines that were not safe. We noted when staff were giving ‘as and when’ medicine they were not always recording the reasons this was given. For example, 1 person was routinely being given an anti-psychotic medicine at night. Staff were just recording this was for ‘agitation’. However, the person’s care notes were not reflecting the person was agitated. This meant the person could have been sedated unnecessarily. There were people that were at high risk of constipation and had been prescribed ‘as and when’ laxative. However, staff were not always recording whether a person had opened their bowels. In one instance there was no recording for 7 days as to whether the person had opened their bowels. According to their medicine record they had not been given the additional laxative. This meant there was a risk the person was not given medicine when needed. The ‘as and when’ guidance for all medicines was not clear which was particularly important for those people that were unable to verbally communicate. This meant there was a risk people may not be offered additional medicine if needed. Other elements to the management of medicines were safe. Creams and lotions were dated when opened. There was information on how the person liked to take their medicines and details of any medicine allergies they had. Staff signed medicines records to confirm they administered medicines to people as prescribed.