The Care Quality Commission (CQC) has rated Montague Court in Edgbaston, Birmingham, inadequate and placed it in special measures following an inspection in February.
This inspection was carried out due to receiving information of concern regarding training compliance, staff supervision and lack of opportunity for staff and people using the service to give feedback about the hospital.
Montague Court is a long-term complex care rehabilitation mental health hospital for up to 18 males. It is registered to provide care and treatment to people detained under the Mental Health Act. At the time of this inspection there were 16 people resident at the service.
Due to concerns found at this inspection, CQC has taken enforcement action and served the provider with a warning notice regarding their information systems. This requires them to make immediate improvements. The hospital has provided CQC with an action plan outlining how it intends to address the areas of concern in the warning notice.
Following this inspection, the hospital’s overall rating, as well as for being well-led, have dropped from outstanding to inadequate. The safety rating has declined from good to inadequate. Effective, caring and responsive have gone from good to requires improvement.
The service is now in special measures which means it will be kept under close review by CQC and re-inspected to check on the progress of improvements.
Amanda Lyndon, CQC interim deputy director of operations in the midlands, said:
“During our inspection of Montague Court, we found the standards of care had significantly deteriorated since our previous visit, people weren’t safe and were at risk of avoidable harm.
“The hospital didn’t provide an environment which was clean, well maintained or fit for purpose. We found staff couldn’t observe people in all parts of the hospital; we saw multiple blind spots which weren’t mitigated by any mirrors or individual risk assessments. Also, the standards of cleanliness were well below what people should be able to expect. It was visibly dirty with food on both the furniture and floor which is totally unacceptable, and nobody should have to live in these conditions.
“Staff didn’t always develop care plans which were holistic and recovery-orientated or record the persons involvement in developing their plan. Also, they didn’t regularly review and update care plans which could result in people not receiving appropriate care to meet their individual needs.
“However, throughout the inspection we did see staff treating people with respect, and they offered people a choice of food and drinks. People told us they were offered a variety of good quality food.
"The overall decline in these standards isn’t good enough and we’ve told the provider what they must do to improve, as nobody should ever have to live in a service which is unsafe.
“We will continue to monitor Montague Court closely to ensure the necessary improvements are made urgently to keep people safe and free from harm. If we are not assured people are receiving safe care, we will not hesitate to take further enforcement action, even if this results in closure of the service.”
Inspectors found:
- There were multiple ligature points which had been identified on the ligature risk assessment, but the risk mitigation actions documented were not followed by staff. Safety knives, used by staff were stored in locked rooms with no signage to indicate their presence
- There were insufficient alarms to keep staff, visitors and people safe
- Staff did not routinely check medical equipment. Blood glucose monitoring machines were not routinely checked or calibrated
- Staff did not receive regular supervision and annual appraisals
- Staff did not follow General Data Protection Regulations (GDPR) to keep people’s information confidential
- The governance systems in place were not sufficient to identify potential risk to people. Significant risks were identified that the hospital had not recognised, assessed, monitored, and mitigated. This represented significant failings in the overall hospital governance processes as the hospital was not aware of the level of risk regarding multiple issues.
However:
- Staff used a full range of rooms and equipment to support treatment and care. There was a dedicated activity centre which had a therapy kitchen, IT suite and games room. The hospital had quiet areas and a room where people could meet with visitors in private, including a dedicated family room. People had access to their own mobile phones.