Scissett Mount

Updated 2 March 2024

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

On day 1 of our inspection, an inspector and an Expert by Experience visited this service. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service. Day 2 of this inspection was carried out by 2 inspectors.

Service and service type

Scissett Mount is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Scissett Mount is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was not a registered manager in post. The home manager was in the process of applying to become registered with us.

Notice of inspection

The first day of our inspection was unannounced. We gave the provider 48 hours' notice in advance of day of 2 of our inspection.

What we did before the inspection

We reviewed information we received about the service since the last inspection. We sought feedback from the local authority and Healthwatch. Healthwatch is an independent consumer champion which gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

During the inspection, we spoke with the home manager, deputy manager, a care unit manager, 3 senior care workers and 3 care assistants, a housekeeper, a handy person, a cook, an activities coordinator, a visiting healthcare professional and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We spoke with 10 people who lived at this home and 5 relatives. We looked at multiple medication records and specific sections of care plans for 6 people. We looked at quality assurance and other records following the inspection.

Updated 2 March 2024

About the service

Scissett Mount is a care home registered to provide residential care to a maximum of 85 people. At the time of our inspection, the provider was providing accommodation for older people and those living with dementia. On the first day we inspected this service, 69 people were living in the home. On day 2, this number was 71.

People’s experience of using this service and what we found

Risks to people were not fully assessed and recorded in sufficient detail in care records. Senior staff responsible on each floor were aware of individual risks to people. Some people were without access to call bells which meant we were not assured they could alert staff if they needed assistance.

A wide selection of audits were being carried out, although these were of a variable quality. Audit scores were not fully reflective of the issues identified. Audits identified that some people needed risk assessments for behaviour which may challenge others and falls, although the timescale for these actions did not reflect the urgency associated with the risk. The home manager’s daily walkaround had not been recorded for approximately 6 weeks and this task had not been delegated to anyone else. There had been insufficient monitoring of maintenance checks.

The management of medicines was not always safe. Some medicines for 2 people were signed for on the wrong day and risks to another person were not sufficiently recorded in their ‘as required’ protocol. Medicines administration was safe, and staff were trained and had their competency checked.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, mental capacity assessments were not in place for some people. Action was being taken to address this. People were given choice in different aspects of their daily living.

People and relatives consistently told us they felt safe and protected from harm. Safeguarding systems were used to record concerns, which we could see were followed up.

Staffing levels were sufficient to meet people’s needs. Staff were recruited safely as relevant background checks had been completed. A small group of people were part of the interviewing panel when the role of home manager was being recruited to in 2023.

People and relatives provided positive feedback about Scissett Mount. Staff we spoke with reflected positively on the management team and said they felt supported. Meetings for people, relatives and staff were taking place and opportunities to feedback were available.

The provider developed strong working relationships with partners in the community. Weekly clinical meetings were effective in discussing people’s changing needs. An inter-generational reading event received positive feedback.

The management team were eager to make the necessary improvements in the service and were working with the local authority as well as a registered managers’ network.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 25 March 2023).

Why we inspected

We received concerns in relation to the safe management of medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led key question sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Scissett Mount on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the safe management of medicines, management of risks to people and systems of governance and oversight.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.