Mortain Place Care Home

Updated 6 April 2023

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was undertaken by 1 inspector.

Service and service type

Mortain Place Care Home 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. Mortain Place Care Home 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. However, a manager had been recruited and had submitted their application to register.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. The provider completed a Provider Information Return (PIR) on the 13 August 2022. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We reviewed documentation, inspected the safety of the premises and carried out observations in communal areas. We spoke with 13 people who used the service about their experiences of the care and support they received and 8 visitors. We spoke with 11 members of staff including the regional manager, training manager, deputy manager, and care staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. This was undertaken in two of the four communities.

We looked at a range of records. This included the care and medicine records for 7 people and 4 staff files in relation to recruitment. Policies and procedures, environmental safety and information relating to the governance of the service were also reviewed. We also spoke with 4 relatives over the telephone and 5 healthcare professionals on the 12 February 2023.

Updated 6 April 2023

Mortain Place Care Home is registered to provide residential care for up to 80 older people, including those people living with dementia. Accommodation was provided over two floors. and divided into four named units, known as communities. The ground floor provided care and support for people who lived with general frailty and a range of conditions such as Parkinson’s disease and mobility problems. The upper floor was a dedicated Memory Lane Community for people who lived with dementia. There were 73 people living at the home at the time of the inspection.

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

Risk management needed improvement to ensure peoples’ health and well-being was protected and promoted. We identified shortfalls in respect of the management of specific health problems. For example, management of weight loss, and diabetes. Staff had not had the necessary training to meet people’s individual needs including catheter care. Some aspects of medicine management needed to be improved to ensure people’s safety.

The governance of the service had not supported the service to consistently improve and sustain safe care delivery. Audit systems and processes, whilst in place, had failed to identify risks to people's safety and other aspects of the service that required improvement. There was a lack of clear and accurate records regarding some people's care and support. For example, diabetes and support with hydration. Communication handover sheets were not informative and not used effectively to inform staff. They were missing vital points for staff to follow up on, such as food and fluids to be encouraged, and people being unwell. Changes to people’s health and well- being were therefore not always planned for and monitored effectively.

We received positive feedback from relatives about the quality of care provided to people living at Mortain Place. Relatives told us they felt staff were kind and caring.

People received care and support from staff who had been appropriately recruited and trained to recognise signs of abuse or risk and understood what to do to safely support people. People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible.

There were COVID-19 policies in place for visiting that was in line with government guidance. Families told us that they were welcomed into the home and followed the guidance currently in place.

Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.

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

Rating at last inspection and update

The last rating for this service was Good (published 03 August 2021).

Why we inspected

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

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

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 safe and well led 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 reports’ link for Mortain Place Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.