Montfort Manor

Updated 19 November 2021

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 Care Act 2014.

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

The inspection was completed by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Montfort Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. This means the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

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 was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with four people who used the service and four relatives about their experience of the care provided. We spoke with seven members of staff including the operational support manager, deputy manager, two team leaders, a senior carer and two activity staff.

We reviewed a range of records. This included 10 people’s care records and multiple medication records. We looked at eight staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at quality assurance records and survey results.

Updated 19 November 2021

About the service

Montfort Manor is a residential care home providing personal and nursing care to 47 people aged 65 and over at the time of the inspection.

Montfort Manor accommodates up to 68 people across three separate floors, each of which has separate facilities. One of the floors specialises in providing care to people living with dementia and another with nursing needs.

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

People did not always receive person-centred activities meaningful to them as information about peoples likes and interests had not always been used to plan activities for them. Despite the service’s excellent outdoor facilities, we observed people living with dementia did not have a walk in the garden or go outside all day. We made a recommendation for the provider to review their management of activities for people, in particular for people living with dementia.

People’s communication needs were known but there was potential improvement to use more alternative methods of communication such as the use of pictures. We made a recommendation the provider reviews their use of alternative communication methods for people, especially for people living with dementia.

People were protected from abuse and avoidable harm. People and their loved ones we spoke with told us they felt safe and staff were knowledgeable in their duties to keep people safe. Risks to people and from the environment were fully assessed and managed to support people to stay safe. Accidents and incidents were reviewed to understand lessons learnt and prevent reoccurrences.

There were enough safely recruited staff deployed to keep people safe and meet their needs.

People were supported to take all their medicines safely and told us they were happy with the care they received for their medicines. We were assured that the provider was managing infection prevention and control effectively.

People’s care needs were fully assessed and included their preferences to ensure their needs were met and clear outcomes planned. Staff were well supported to ensure they had the knowledge, skills and competence to fulfil their roles.

Mealtimes were a positive experience for people, people’s choices were promoted, and people were supported to remain safe from risks around eating and drinking. People’s healthcare needs were monitored and met. Staff worked with other healthcare professionals when required to achieve this.

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.

People were treated with respect by staff who were kind, caring and attentive in their interactions with people. People were supported to make choices about their care and day to day living. People’s loved ones told us they were kept informed and involved in their care.

People's rights to privacy and confidentiality were respected and people’s dignity was maintained.

People were supported to maintain their independence where possible and their care plans informed staff what they could do for themselves and when they needed support.

Peoples care records contained person centred information to ensure people’s care was relevant and meaningful to them. All people and their loved ones knew how to raise a complaint if they needed to. All people and their relatives we spoke with were very positive about Montford Manor and no-one had any complaints.

People’s wishes around their end of life care were recorded and where people were on end of life care, medicines were available to ensure they could remain pain free.

There was no registered manager in post at the time of inspection. However, there were robust interim arrangements with a manager in place who knew the service well. The manager had created a positive, person centred culture in the service. All staff, people and relatives were positive about the manager.

The manager had ensured high quality and safe care for people. Care records were detailed and up to date. Risk management systems were robust. Quality assurance audits and reports were used to check people’s safety and quality of care. Staff worked well together, and there were regular staff meetings to ensure good communication.

The provider and manager proactively sought to identify and promote improvements in the service. Quality assurance systems such as audits and surveys were completed alongside other feedback and events, such as incidents to ensure continuous improvement. The manager monitored their progress with any action plans for improvements to ensure these were completed.

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

Rating at last inspection

This service was registered with us on 17/10/2019 and this is the first inspection.

Why we inspected

This was a planned inspection following a new registration.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.