Montague Court

On this page

• 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 reviewed 7 quality statements. These were learning cultures, safe systems, pathways and transitions, safeguarding, involving people to manage risk, safe environments, safe and effective staffing and infection prevention and control. People and staff were aware of how to raise concerns but were not always confident they would be treated with compassion and understanding. There was not always learning identified and action taken to resolve people’s concerns. People’s needs and risks were discussed in handovers between shifts but these were not always documented to ensure all staff were aware of these. The provider trained staff in safeguarding but some staff were not confident that the systems to protect people from abuse were always effective. People’s risks were assessed and understood by staff however, some staff were not updated on people’s changing risks. There were enough staff to keep people safe. However, staff did not all understand the service’s aims of rehabilitation. People were cared for in a safe environment however, the arrangements to monitor the safety and upkeep of the premises were not always effective. People were generally protected as much as possible from the risk of infection. However, hand hygiene processes were not adhered to by all staff.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

One person commented that the ‘food quality was poor”. This was highlighted in the patient survey in 2021. Following our assessment the provider told us that the occupational therapist had commenced work in March 2024 about people's nutrition and a new menu was launched in August 2024. This work was linked to the nutritional standards for care settings document and was completed with input from the people who use the service at Montague Court. Staff did not understand the service aims and values. We saw poor engagement from staff during the mealtime. This was reflective of a poor culture of communication and one person commented they “felt scared” of staff.

Some staff found caring for patients challenging due to incidents involving racial slurs and threats. Staff were provided with reflective practice sessions. Sufficient lessons and learning from incidents were not identified in the investigations.

Incidents were reported on the electronic incident reporting system which all staff could access. These incidents were reviewed by the nurses and managers. If learning was identified this was discussed in staff handovers. Managers carried out monthly incident scenarios and feedback from these were discussed in staff meetings and clinical management meetings. A recent incident scenario completed showed how this was fed back and learning identified and recorded. Learning was then discussed at the services quality governance board meetings. However, in the meeting minutes reviewed there was no evidence of discussion.

There is a balanced approach to risk that supports people. This was reflected in risk assessments which were detailed. The provider showed examples of rehabilitation work with people using the service that included formal observation of staff undertaking tasks such as road safety or cooking with people to ensure this kept people safe.

Staff told us they discussed people’s needs and risks during daily handovers between shifts and had access to the electronic records system. However, staff were not clear if they always referred to this information to ensure consistent support was given.

People’s needs were managed and shared regularly on a daily handover and on the electronic records system. However, it was not clear if staff always referred to this information to ensure consistent support was given. People could make complaints through the comments box, during community meetings and to staff who would then follow the complaints procedure . No recent complaints had been made.

Some staff felt safeguarding and governance structures were weak and patient issues, when raised and resolved, were not fed back. Management have provided lessons learnt. Evidence did not show lessons have been filtered down to staff or the people using the service.

We observed that staff did not always engage with people when observing them. However, the provider showed us for one person how this was included in their care plan and when possible staff did engage with them whilst supporting them with their mobility needs.

The provider trained staff in safeguarding adults from abuse and harm. There were processes in place to report allegations of abuse to the local authority as needed. The provider’s risk register showed a safeguarding issue identified by leaders was managed in a timely way.

People said their risk assessments were discussed in their multidisciplinary team meeting, and they were involved in these. People told us restraint was not used at the hospital and they had not been restrained there.

Staff said they were involved in people’s risk assessments. They had access to these on the electronic patient’s records system although did not always have time to read if people’s risks had changed. The provider told us that all staff on duty attend the daily handovers where any changes to people's risks are handed over. They also said all staff attended the risk assessment formulation process for each person's risk assessments. However, at the time of our visit staff told us they did not always have time to have updated information about each person's risks.

People were supported to understand and manage risk. Risk assessments were clear and provided sufficient guidance to staff to keep people safe. People’s risk assessments were updated during their meeting with their multidisciplinary team. However, it was not always easy for all staff to be kept updated of people’s changing risks. There were verbal handovers between each shift. The provider told us that handovers were always documented and all staff attended. Handovers were saved on the shared drive and a hard copy available for staff to read in the nursing office. Staff assessed people before they went on leave from the hospital and documented this appropriately.

The environment was clean and tidy. Cleaning staff have increased to three full time. The equipment was maintained and regularly audited. Ligature cutters were available in 3 locations and the cupboards were all clearly labelled and marked. One set of cutters was hidden under linen and not easily accessible in an emergency. This was fed back to the manager at time of our visit who agreed to address. Fire safety measures were recently reviewed and updated following a fire drill and audit. This was shared and evidenced in meeting minutes. There were unmonitored areas on the wards, corridors and stairs. These were mitigated with the use of mirrors and observation levels. The equipment was maintained and regularly audited. Ligature cutters were available in 3 locations and the cupboards were all clearly labelled and marked. However, one set of cutters was hidden under linen and not easily available or visible in an emergency. There were facilities to meet people's cultural needs and for families to visit. People had access to their mobile phones and could make their own hot drinks and snacks as they wished.

The water dispenser was not working. It was not clear how long this had been out of service as there was no record of the environmental checks. Community meeting minutes showed several maintenance issues and repairs reported to staff during the meeting. There was no evidence these were reported on the maintenance report. There was no evidence of how this process was monitored. Staff meeting minutes documented that the defibrillator machine had no pads attached and staff did not know where these were kept. While a reminder for staff to 'familiarise themselves with defibrillator equipment’ was stated, there was no evidence of additional training being provided to staff. The service had implemented 4 hourly environmental walkaround checks which was an improvement from our previous inspection.

Some people said that staff did not always support them in the way they wanted and did not understand their needs.

Staff lacked understanding in rehabilitation and said they did not have training on this. Some staff were not aware of the rehabilitation aspect of the service, and this was considered the role of occupational therapists.

We observed that some staff interacted well with people and explained things to them to reduce their distress. However, during the mealtime there was limited interaction with people and staff stood watching people eating with no engagement.

All staff have an induction to the hospital which takes place over several shifts during which they are not counted in the numbers so that they can learn and adapt to the environment and model the existing staff. All staff then attend a one day corporate induction for the provider. There was one registered nurse and one healthcare support worker vacancy at time of our visit. The multidisciplinary team was fully staffed. Staff rota systems were consistent and well monitored. Staffing levels were appropriate and skill mix to make sure people received consistently safe care that met their needs. There was a varied mix of specialist staff available to ensure suitable interventions. Bank or agency staff were often used to cover night shifts. Rotas showed that it was difficult to cover night shifts with regular, permanent staff. Staffing rotas from 6 to 26 May 2024 showed there were 24 night shifts that required agency registered nurses and 38 night shifts that required agency health care support workers. The service used regular named agency staff and a regular agency provider to provide consistent familiarity for people who used the service. At the time of our visit the deputy manager was on a temporary contract from the agency and they then transferred to the permanent staffing group.

People told us their rooms were kept clean. People cleaned their rooms weekly to develop their domestic skills with the help of staff where needed. In addition domestic staff cleaned people's bedrooms every week. People said the communal areas were kept clean by domestic staff.

The hospital was clean and hygienic. However, a nurse did not wash their hands before giving medicine to a person. There were three full time domestic staff in post.

The service had quarterly compliance checks in place for hand hygiene. The completed checks for April showed staff were compliant with this. The service had an ‘infection prevention standards compliance tool’ in place which was detailed. The completed audits for March and April showed staff had not actioned when an issue was found. For example, in March and April staff identified new staff had not received hand hygiene training or level 2 food safety but there was no action for this. Staff completed monthly mattress audits and actions from these were completed.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.