Clare Mount

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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 2 breaches of regulations in relation to safe care and treatment under this key question of safe. People’s individual risks were not accurately recorded and not always managed safely and we found continued concerns with the safety of the environment. We were not assured that safeguarding concerns and events were always fully reported and investigated. Relatives told us they felt their loved ones were safe. Medicines were mostly managed and administered safely. There was enough staff to meet people’s day to day needs; however, we were not assured they were suitably trained and competent to provide safe and effective care. Staff had received training in safeguarding; however, they had not recognised or actioned the safeguarding concerns we found and reported on this inspection. Processes around people’s mental capacity, their ability to consent to care and treatment and deprivation of their liberty were not always adequate and we identified a breach of regulations relating to consent.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People's relatives told us they felt their loved one was safe at Clare Mount. They told us the staff would contact them if there had been any incidents. One relative told us, "Being in Clare Mount is a relief as I know my [relative] is safe, they do have falls but I am called at once." We found care plans and risk assessments were not always reflective of people's needs and not updated when incidents occurred, therefore, we were not assured that improvements were made to people's safety as a result of an incident or accident.

The registered manager told us they carry out an analysis of trends around accidents and incidents and discussed these in handover and staff meetings. One staff member told us they have '10 at 10 meetings' to share information, but we did not see these happen and did not see evidence of these on our site visits and we did not see any documentation recording these meetings.

There was a system in place to record accidents, incidents and safeguardings to review and learn lessons but it was not clear how effective this process was in reducing risks to people especially around people's distressed behaviours. We were not assured all accidents and incidents were recorded, reported and addressed and we were not assured that we had been notified of safeguarding incidents or that they had been recorded at all. The home was under a fire enforcement notice from Greater Manchester Fire and Rescue Service, but we saw this had not always been complied with in a timely manner; for example, we found an external exit was still padlocked. We found continued concerns on this inspection about the environment and people's safety and care that had not been addressed since we last visited. The registered manager told us there had not been any complaints since the last inspection.

People's relatives were happy with their loved one's safety at Clare Mount. One relative told us, " I get calls if [relative] is unwell and together we discuss the next steps." Although people's relatives gave positive feedback about their loved one's safety at the home and did not raise any concerns with us about referrals to healthcare professionals, we found people's experiences was that they did not always receive timely healthcare input when needed. We raised safeguarding alerts for some people as a result of our findings.

The registered manager and staff told us they made referrals to other healthcare professionals when people needed this input. They told us they were able to identify when someone needed a referral to services such as podiatry and speech and language therapy (SALT). However, on review of care plans and during our site visits we found this did not always happen in practice. Staff told us they found it problematic to ensure the local GP service and other healthcare professionals provided timely medical attention. For example, we found one person had an eye problem and we reported this to the nursing team on the first day of our site visit. We found this person had not received medical attention when we returned 6 days later and staff could not confirm when the person would be seen by a professional. We raised a safeguarding alert to the local authority about this person's care and safety.

The service was under a multi-agency concerns (MAC) process at the time of our inspection and they had alerted us to their concerns. Feedback on these meetings from other health and social care professionals involved in the home was that they were concerned about the care people received at the home. The local authority was closely monitoring the home and conducting a number of ongoing safeguarding investigations at the home and other professionals were working closely with the home's management to ensure the safety of people at the home.

The registered manager and staff told us there were systems in place to monitor people’s health and safety and therefore take action to make timely referrals to safely manage any concerns. However, we found people's care documentation was conflicting, not reflective of the person's needs and not always accurately recorded. People's monitoring charts, such as weight checks were not always accurate and we did not see where necessary and timely referrals to other healthcare professionals had been made. One person was visibly underweight and was suffering from a wound; however, they had not been referred to a dietician for additional help and advice. Another person had a visible wound on their face and this was not documented anywhere in their care records and staff were unable to explain to us how the wound had occurred and how it was being managed. We raised safeguarding alerts to the local authority due to our concerns about these 2 people's care and safety.

Relatives we spoke with did not raise any concerns with us around safeguarding at Clare Mount. One relative told us, “If my [relative] was in any danger they would be moved at once. I have never seen anything that concerns me.” However, we found people’s experience of safe care did not match the feedback received from relatives and we found people were not always safeguarded from harm.

The registered manager told us they follow local authority governance arrangements for reporting concerns and for notifying CQC of abuse or allegations of abuse. However, we were not assured that staff and management were able to identify and action concerns and risks of abuse. Staff told us they had received training and the registered manager produced a list of training completed by staff that included safeguarding training. However, we were not assured about the effectiveness of the online training as many modules were completed online very quickly and the home had several ongoing local authority safeguarding investigations prior to our inspection. We also identified people living at the home who were at the risk of harm where staff and management had not taken action to safeguard them from them from abuse.

We observed several instances of poor care relating to moving and handling, personal care, the management of individual risks and the safety of the environment. We reported our concerns to the management and the local authority. For example, we observed one instance where a person was lifted in a hoist and the person was still strapped into their wheelchair causing them distress and placing them at the risk of harm.

Processes to ensure people’s mental capacity and ability to consent had been considered were not adequate and we found the service was in breach of regulations. We found consent forms were not always signed or they had been signed by relatives who had no legal powers to consent to care and treatment on behalf of the person. Mental Capacity Act (MCA) assessments of people's capacity to make decisions were poor. One person had several mental capacity assessments carried out by staff and these were not always completed appropriately. For example, the MCA assessment for the use of bed rails and the use of a call bell were poorly completed and the decision was made unilaterally by a senior carer with no evidence of any best interests decisions or meetings. The lack of robust assessments and staff understanding in relation to MCA placed people at the risk of unnecessary restriction. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found people had a DoLS in place; however, conditions associated with depriving a person of their liberty had not always been incorporated into care plans and adhered to. We requested a safeguarding policy to be uploaded to our system but this was not received. The registered manager told us they had a safeguarding champion, a safeguarding noticeboard and that they do walk-arounds and randomly go and check around the home. They also told us they check the care documentation writing. However, none of these safeguarding processes had identified and addressed the concerns we found on inspection that led us to raise 3 safeguarding alerts with the local authority.

People were not always supported appropriately and safely with their individual conditions and did not always receive their care and support in a safe way. Care plans did not demonstrate that people and their families were always involved in managing risks as this was not reflected in documentation. However, relatives told us they felt involved in their loved one’s care and support.

The registered manager told us people’s risks were reviewed monthly and any changes were documented and passed to staff through handover and communication channels. The registered manager told us people do not always understand discussions around risk management so risks are discussed at meetings with the family. However, we did not see any evidence that people or their relatives were involved in assessing or managing people’s risks. Staff told us people’s risks were documented in their care plans and they are kept informed when people’s needs change. We received mixed feedback from staff about their knowledge around people’s diets and fluids and their opportunities to have time to read through people's care plans.

We found concerns during our observations that people were not receiving support in line with their risk assessments. For example, we observed one person at risk of falls was not wearing suitable footwear in line with their care plan; another person’s risk assessment stated they walked independently; however, the person had poor mobility and walked with a frame. We also found people did not always receive a dietician referral when required. Our observations identified concerns with the safe moving and handling of people by staff at the home. We were not assured as to the efficacy of the training programme for staff as staff did not demonstrate they were knowledgeable about people’s risks nor proficient in the moving and handling of people.

The management of people’s individual risks to keep them safe from harm was not adequate and we found a breach of regulations relating to risk. Individual risk assessments were in care plans for people; however, these were not always accurate and reflective of people’s current care needs and we had concerns regarding the safe monitoring of people’s risks. These included inaccurate records of people’s weights and poorly completed repositioning charts. We did not see where robust action had been taken to remedy this risk.

Some areas of the home were in poor condition and required refurbishment. The only bath had been condemned as unfit for use by local infection prevention and control teams. The first-floor shower room was unclean and required replacement. The downstairs shower room and two bedrooms were malodorous. The provider had made some efforts to make the home dementia friendly; however, the home did not have a homely feel in most areas. The home’s environment, layout and décor did not meet the needs of people living with dementia in line with best practice.

The registered manager told us they did several checks on the environment and buildings, including daily walk arounds. They told us they carried out health and safety checks and audits. The deputy manager told us they now carry out weekly fire drills. However, these checks had not identified and actioned the concerns we found with the safety and appropriateness of the environment. For example, some taps were too hot but this had not been identified in any of the completed water checks.

We observed concerns with the environment that posed a specific risk to people’s health and safety. For example, the interior of the passenger lift was in very poor condition and unclean. We found uncovered radiators and unsecured wardrobes in people’s bedrooms. We observed people’s bed rails did not always fit appropriately and several people did not have bed rail covers. The inappropriate and unsafe use of bed rails meant people’s risks of falls and entrapment was not managed safely.

The provider had not ensured adequate measures to ensure the health and safety of people and to safely mitigate risks. This demonstrated a breach of regulations relating to safety. The completed environmental safety checks were not effective had not ensured the building, environment and equipment was clean and safe. For example, the registered manager showed us a tick exercise that indicated people’s bed rails were visually checked each day; however, there was no information around what was being checked and no evidence the bed rails adhered to safety standards. We found no evidence that people’s bed rails had been checked for suitability and safety in line with published national guidance. On our first site visit, we found people had unimpeded access to the outside space and potentially hazardous areas in the grounds of the home. This meant people could leave the building unobserved and placed them at the risk of harm.

People’s relatives did not raise any concerns with us about the number of staff on duty and gave positive feedback about the competencies of staff.

The registered manager told us they carried out staff induction, supervision of staff and also conducted staff competency checks for medicines and catheter care. They told us they would adjust staffing levels when required. Staff told us they were happy with the staffing levels and the training they received. However, staff did not always demonstrate knowledge about the training they had completed. For example, one staff member did not understand our questions around what learning disability and autism training they had completed.

We found there was enough staff on duty to respond to people’s needs in a timely way. However, we were not assured that senior staff had protected time to carry out additional tasks, such as management of staff and ensure care plans and risk assessments were up to date and accurate. There were 7 people who received 1:1 funded care and therefore, we observed many staff present in communal areas. Although we had no concerns about the number of staff on duty, we observed staff did not demonstrate sufficient knowledge of people, understand their needs and were not always able to effectively communicate with people. We observed multiple incidents of poor and insufficient care delivery and we were not assured that staff were appropriately trained to provide safe and effective care to meet the specific needs of people at the home.

We found most staff working at the home was doing so under the health and care worker visa sponsorship scheme. The registered manager told us that many of the staff had high level qualifications from their country of origin and they produced a training matrix to demonstrate staff training completion levels at the home. We were not assured about the efficacy of this training as the matrix demonstrated staff had completed a very high number of training modules in a short space of time. For example, the matrix recorded one staff member had completed 52 training modules over 2 days. We were not assured that staff were effectively trained in mandatory modules nor competent to support the specific needs of people at the home.

Relatives gave positive feedback about infection prevention and control (IPC) procedures at the home and did not raise any concerns with us about cleanliness. Relatives also told us staff wore personal protective equipment (PPE) when required. One relative commented, “The staff do use PPE, and the home is clean and currently undergoing an upgrade.”

The registered manager told us staff had received practical training in hand hygiene and the donning and doffing of PPE. They also told us they would physically observe staff’s infection control and PPE practice in the home.

We observed several areas of the home were in poor condition and required deep cleaning and refurbishment. This included some people’s bedrooms. People did not have access to clean and good quality bathrooms. We found the first floor shower room was old and required a deep clean. The ground floor shower room was in good condition; however, there was a strong malodour. Most of the home was surface clean; however, we found some people’s bedrooms required a deep clean. We observed staff to wear PPE when required during personal care and when serving food.

The registered manager told us they carried out IPC audits of the building and that staff had received IPC training. The training matrix confirmed staff had received training in IPC and use of PPE. We could see improvements had been made in the home since the last local authority IPC audit; however, we found improvements were still required and the home’s own audits had not identified or actioned the concerns at the home prior to the IPC audit. The registered manager told us they had had another local authority IPC audit just before our first site visit; we requested the outcome of this be emailed to us; however, this was not received. The Food Standards Agency had visited shortly before our site visits and rated the home 2 out of 5 for hygiene.

Relatives did not raise any concerns with us about the safe management and administration of medicines at the home. One relative told us their family member had not had any medicine changes for a while and confirmed they were always informed by staff if that happens.

The registered manager told us they were a registered nurse and was therefore qualified to carry out the medicine administration and management competency checks of nursing staff. They told us if a medicine error had occurred, they would report the incident to family and the local authority and conduct a lesson learnt exercise. The registered manager told us they had recently had an external medicines audit completed by their pharmacist; a copy of this was sent to us and there were no concerns found on this audit.

On completion of our medicines review, we did not find any significant concerns with the administration and management of medicines at the home. We found staff maintained good hygiene and showed people dignity when administering medication. Staff ensured they witnessed people swallowing their medicines and nursing staff were very patient and caring in manner during administration. The nurses’ clinic room was organised and tidy. We found medicine administration records were in order, completed fully and contained the necessary photograph of the person.