Mount Pleasant Residential Home

Updated 13 May 2022

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

The inspection site visit was completed by two inspectors.

Service and service type

Mount Pleasant Residential 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. Mount Pleasant Residential 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 service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

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. We sought feedback from the local authority and professionals who work with the service. 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

We spoke with eight people who use the service and six staff including the provider, registered manager, senior support worker, support worker and ancillary staff. We looked at the medicine’s records for five people who used the service and care records for six people. Governance records were also reviewed and included quality monitoring audits, accident an incident records, maintenance, servicing records and personnel files for four staff members.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records along with policies and procedures. We contacted five relatives of people who use the service by telephone.

Updated 13 May 2022

Mount Pleasant residential home is a care home providing personal care. The service provides support to 25 people aged 65 years and over. At the time of our inspection there were 20 people using the service.

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

We found significant improvements had been made at the service since our last inspection in May 2021. The home had undergone a major refurbishment programme resulting in positive improvements to the environment. Governance systems were used to identify and drive improvements across the service.

Infection prevention and control systems had been improved and all previous concerns relating to health and safety had been addressed. All areas of the service were visibly clean and enough housekeeping cover was now in place.

The management and administration of medicines had improved and was robust with clear procedures in place. The management of people’s ‘as required’ medicines was now safe with clear and consistent records. People’s prescribed creams were now stored securely.

People’s care plans and risk assessments had been reviewed and updated to ensure person centred language was used. They reflected people’s individual needs and preferences. People who used the service told us they felt well cared for and listened too. They said staff were extremely kind and responsive to their needs.

Safe recruitment procedures were in place. The staff and management team worked closely with health and social care professionals to ensure the best outcomes for people.

People were protected from the risk of abuse. Safeguarding policies and procedures were in place. Staff had received training and understood how to keep people safe and who to report to if they had any concerns.

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.

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.

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 inadequate (published 29 October 2021) and there were three breaches of regulation relating to medicines, infection prevention and control, risk management and governance. We took enforcement action and imposed conditions on the provider’s registration meaning they had to submit monthly reports to demonstrate the actions they were taking to drive improvements. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. The conditions we imposed were removed following this inspection.

At our last inspection we recommended that the provider reviewed their staffing levels to improve and sustain levels of cleanliness within the service. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider had acted on this recommendation. Staffing levels were enough to maintain the cleanliness of the service.

This service has been in Special Measures since 29 October 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 inadequate to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mount Pleasant Residential Home on our website at www.cqc.org.uk.