This inspection was carried out on 11 April 2018. The inspection was unannounced.

We carried out an unannounced comprehensive inspection of this service on 2 March 2017, where the service was rated as Good overall. After that inspection we received concerns in relation to an incident where a person died in hospital following a period of respite. The concerns related to meeting the nutrition and hydration needs and meeting people’s health care needs. As a result we undertook a focused inspection to look into those potential concerns. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Mont Calm Residential Home on our website at www.cqc.org.uk”

We undertook an unannounced focused inspection of Mont Calm Residential Home on 11 April 2018. The team inspected the service against three of the five questions we ask about services: is the service well led, is the service effective and is the service responsive to people’s needs. This was due to the concerns that had been raised, and the potential risk to others living at Mont Calm Residential Home. At this inspection the service was rated as requires improvement in effective, responsive and well-led. Therefore the overall rating for the service is now requires improvement.

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

Mont Calm is a privately owned care home providing accommodation and personal care for up to 39 older people, some of whom are living with dementia. The service consists of two properties next door to each other with a pathway connecting the two. There is a lift to enable people to move between different floors. There were 32 people living in the service when we inspected.

The service had a registered manager in post who managed the service during the full comprehensive inspection in March 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At this inspection, the registered manager was not aware of all of their responsibilities to ensure compliance with fundamental standards and regulations. They had failed to notify CQC of a notifiable event in a timely manner. This was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Some people’s care plans were detailed and gave staff guidance regarding how to meet people’s needs. However, some people’s care records had not been reviewed and updated for over a period of ten months.

People’s nutrition and hydration needs had been assessed; however, best practice guidance had not been followed to ensure accurate records.

There were standard set amounts of fluid targets for people to drink throughout the day. People received food they enjoyed and specific dietary requirements were catered for. Staff worked with health care professionals to ensure people remained as healthy as possible.

Information was not made accessible to enable people to make an informed choice. People did not always have access to the equipment they required such as, height adjustable tables.

People were encouraged to make their own choices about their lives. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff offered people choices and gained people’s consent prior to any care or support tasks. However, some staff lacked understanding

We inspected this service on the 2 March 2017. The inspection was unannounced.

At our previous inspection on 12 January 2016 we found breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. A breach of Regulation 19 (2) (a), the provider had failed to ensure recruitment information was available for each person employed. A breach of Regulation 11 (1) (2) (3), the provider had failed to adhere to the Mental Capacity Act (2005), in relation to assessing people’s capacity and a breach of Regulation 9 (1) (a) (b) (c), the provider had failed to provide activities to meet people’s individual needs. The provider sent us an action plan which stated they would meet the regulations by December 2016. At this inspection we found that improvements had been made to meet the relevant requirements.

We required the provider to make improvements in relation to assessing people’s capacity to consent, providing activities to meet people’s needs and the safe recruitment of staff. We found that significant improvements had been made and the provider was now meeting the regulations.

Mont Calm is a privately owned care home providing accommodation and personal care for up to 39 older people, some of whom are living with dementia. The service consists of two properties next door to each other with a pathway connecting the two. There is a lift to enable people to move between different floors. There were 19 people living in the service when we inspected.

At the time of our inspection, there had been a registered manager in place since July 2016. They were an experienced member of staff who had worked for the provider for a number of years. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. At the time of the inspection, the previous registered manager had applied for DoLS authorisations for some people living at the service, with the support and advice of the local authority DoLS team. The registered manager and the management team understood their responsibilities under the Mental Capacity Act 2005. Mental capacity assessments and decisions made in people’s best interest were recorded. People were actively encouraged and supported to make decisions relating to their lives.

People experienced a service that was safe. Staff and the management team had received training about protecting people from abuse, and they knew what action to take if they suspected abuse. Risks to people’s safety had been assessed and measures put into place to manage any hazards identified. The premises were maintained and checked to help ensure the safety of people, staff and visitors. People’s safety in the event of an emergency had been considered, assessed and recorded.

People participated in activities of their choice within the service and the local community. There were enough staff to support people to participate in the activities they chose.

There were enough staff on duty with the right skills to meet people’s needs. Staff had been trained to meet people’s needs. Recruitment practices were safe and checks were carried out to make sure staff were suitable to work with people who needed care and support. Staff had received the training they required to meet people’s needs. Staff were supported in their role by the management team.

People received their medicines safely and when they needed them. Policies and procedures were in place for the safe administration of medicines and senior staff had been trained to administer medicines safely. People were supported to remain as healthy as po

The inspection was carried out on 12 January 2016 and was unannounced.

Mont Calm provides accommodation and personal care for up to 39 older people, some of whom are living with dementia. There were 17 people living in the service when we inspected.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was enough improvement to take the provider out of special measures.

At our previous inspection on 27 and 28 April 2015 we found breaches of eight regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action and placed the service into special measures. The provider was required to make improvements. We placed a condition on their registration which related to the carrying out of the regulated activity:

The Registered Provider must limit the number of service users living at Mont Calm Residential Home to 22 and not admit any service users into the home should any of the 22 service users leave the home. The Registered Provider must not admit any new service users into Mont Calm Residential Home, without the prior written agreement of the Commission. This condition also applies to service users requiring respite care.

We required the provider to make improvements in relation to meeting nutritional and hydration needs, good governance, having sufficient qualified, competent, skilled staff to meet peoples’ needs, safe care and treatment, need for consent, person centred care, safeguarding service users from abuse and improper treatment and dignity and respect. We found that improvements had been made; however, the provider remained in breach of three regulations.

There was a manager employed at the service who had applied to the Care Quality Commission to become the registered manager. Their application was in progress at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. At the time of the inspection, the previous registered manager had applied for DoLS authorisations for some people living at the service. However, the principles of the Mental Capacity Act 2005 had not been applied prior to the applications being made. Mental capacity assessments had not been completed and decisions had not been made in people’s best interests. The current manager and staff were aware of their responsibilities under the MCA 2005 and DoLS. The manager planned to complete the MCA assessments with people’s representatives.

There were enough staff on duty with the right skills to meet people’s needs. Staff had been trained to meet people’s needs. Recruitment files did not always contain the required information under schedule 3 of the Health and Social Care Act 2008 (Regulated Activities). Full employment histories had not been requested nor gaps in employment checked or explored at interview. Other checks had been carried out to ensure staff were safe to work with people.

People told us they felt safe. Staff had received training about protecting people from abuse, and they knew what action to take if they suspected abuse. However, some staff required refresher training in this subject. Risks to people’s safety had been assessed and measures put in place to manage any hazards identified.

People were not encouraged to participate in activities that took place and activities were not specific to meet people’s needs.

The premises were maintained and checked to help ensure people’s safety. Health and safety risk assessment relating to staff had not been completed. For exam

During this inspection, the inspector focused on answering five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

The registered manager ensured that staff underwent checks before starting work at the home. For example they checked a person’s character by carrying out Disclosure and Barring Service checks. (DBS). This was formally known as a criminal records check.

During our inspection we saw that staff delivered the care outlined in people’s care plans. For example we observed that staff ensured people were safe when they were lifted because staff used specialist equipment. Also to ensure people’s safety, where two staff were required to carry out a task, we observed that two staff were available.

Procedures for dealing with foreseeable emergencies were in place and staff were able to describe these to us. The manager understood how care would be continued in the event of a foreseeable emergency occurring. Staff had access to support and advice at all times from a senior member of staff.

The provider and staff understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). We saw that people’s rights were protected because the manager understood how to support people to make decisions in their best interest.

The service was kept clean and free from infection because the manager ensured that there was a cleaning schedule and that this was followed.

There were systems in place for making regular checks on the risks of providing the service and safety of the premises. Incidents and accidents were monitored. The manager had made changes as a result of learning from incidents and these had been put into practice.

The manager ensured that there were enough staff to meet people’s needs. We found that that they had ensured that staff had the required skills and knowledge to care for people in a safe way.

Is the service effective?

People had an individual care plan which set out their care needs. We found that the manager used an assessment system that was appropriate for people living with dementia. People’s relatives had been fully involved in the assessment of people’s health and care needs when appropriate. Relatives and other key people had been involved in supporting decisions that had been made in people’s best interest. For example, when people lacked capacity to make the decisions for themselves. People’s care plans were reviewed regularly to check they were still effective. During our inspection we saw staff delivering the care outlined in people’s plans. When people fed back about the service they talked positively about the care provided at the service.

Is the service caring?

We found that people were treated with respect and their dignity was maintained. People appeared relaxed and comfortable with the staff that supported them. We observed that people had a positive relationship with staff. Staff took time to chat with people about day to day matters. People told us that the staff were caring. One person said “X is well cared for, I cannot fault staff”. Other people said “People are very well cared for, the staff are very kind to X”. Other people had commented ‘Staff are very caring, understanding and supportive” and “The staff are kind, they do a good job”. Staff we talked with told us that people were well cared for. We observed that staff were attentive to people’s needs and responded positively when people required their support.

Is the service responsive?

The service reviewed people’s care plans regularly. There was a nominated person in charge of the service with the required training and authority to manage how the service was delivered. The manager or their deputies were available via telephone for further advice when needed.

We found that the manager asked people about what they experienced from the care and treatment they had received. People told us that registered manager had consulted them about the quality of the service.

Is the service well-led?

The provider continually monitored areas of risk in the service and made regular checks on quality. There was evidence that the provider learnt from incidents. Changes had been made to minimise the risks of incidents occurring again.

People’s care was assessed, planned and managed. Staff were aware of people’s care needs. The manager had ensured that the resources required to deliver the regulated activities were available.

Staff were trained and inducted. Team meetings enabled staff to express their views about service quality and they were able to raise issues that concerned them.

The manager ensured that daily checks of the quality and safety of the service were carried out. Regular reviews of people’s care plans took place which ensured their needs were being met.

We carried out this inspection visit to check that compliance actions the provider was asked to carry out following our visit on 29 April 2013 had been completed.

We found that a new management team was in place in the home and improvements had been made.

We saw that a system was in place to make sure people’s consent to care was obtained and that they or their representatives were consulted and involved in planning how their care would be delivered.

Medication was given at the right time, in the right way and recorded accurately to make sure people received the medication they needed, when they needed it.

Where people made complaints about the service, these were recorded and followed up to make sure any concerns were addressed.

Most of the people that used the service at Mont calm had dementia and therefore not everyone was able to tell us about their experiences. To help us to understand the experiences people have we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us about their experiences and we also spoke with visitors to the service.

We saw that people were treated with respect and kindness. People told us they could choose what they wanted to do. They said, “I can get up when I want to.” “Everyone is very friendly.”

During our visit we found that people’s care and welfare needs were met.

There was no system in place to make sure people’s consent to care was obtained or that they or their representatives were always consulted or involved in planning how their care would be delivered.

Medication was not always given at the right time, in the right way or recorded accurately to make sure people received the medication they needed, when they needed it.

Staff received the training they needed to enable them to provide appropriate care and support to people who lived in the home.

Where people made complaints about the service these were not recorded or followed up to make sure any concerns were addressed.

We conducted this inspection visit to review improvements following our last visit on 3 August 2012 when we found aspects of the service which were not compliant with two standards. The provider sent us an action plan to tell us how they would make improvements in the service to make sure that quality assurance systems were effective and adequate standards of hygiene were maintained.

During this visit we found that improvements had been made. We spoke with people who lived in the home. People told us the home was always nice and clean. They said they enjoyed their meals and there was plenty of choice. People felt comfortable to express their views about the service to the provider. We spoke with people who used the service. They told us, “Its always nice and clean.” ”I like it here, the manager is very good.” “The food is very good, there’s always a choice.”

We spoke with people who lived in the home. They said staff were very good and looked after them well. People told us they chose what they wanted to do, when to go to bed and when to get up. They said they were enjoying their meals and there was plenty of choice. People said there were activities and they had residents meetings where they were consulted about what they would like to do and aspects of how the home was run. People told us they felt safe in the home.

People’s comments included, “Staff are good at protecting peoples’ dignity.” “Its always nice and clean.” ” I am very happy here.” “I am very satisfied with the care.” “Everything is done for you.” “Staff are very kind.” “The food is very good, there’s always a choice.” “The staff are very caring and helpful.”

People who lived in this home had dementia and were not able to engage directly with us in the compliance review process. During our visit we saw staff asking people what they would like to do, where they would like to go and what they would like to eat and drink. People who we spoke with told us they were happy living at Mont Calm. We saw that the atmosphere was relaxed and people were content. People told us they liked the food although sometimes there was too much for them to manage all of it. They said staff were very good. We saw that people were very comfortable with the staff on duty during our visit.

This inspection was carried out on 27 and 28 April 2015. This was a focussed inspection to follow up on actions we had asked the provider to take to improve the service people received.

Mont Calm Residential Home provides accommodation and personal care for up to 39 older people. There were 25 people living at the service during our inspection. People had a variety of complex needs including people with mental health and physical health needs and people living with dementia. Accommodation was provided in two adjacent houses. There was a passenger lift between floors in each house.

The service did not have a registered manager. The previous registered manager had ceased working at the service in December 2014. The provider told us that a new manager was due to start working in the service during the week of our inspection.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2014 and associated Regulations about how the service is run.

At our previous inspection on 19 and 20 January 2015 we found breaches of nine regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These correspond with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which came into force on 1 April 2015. We took enforcement action and required the provider to make improvements. We issued four warning notices in relation to care and welfare; safeguarding people from abuse; quality assurance and having enough staff. We found six further breaches of regulations. We asked the provider to take action in relation to nutrition, privacy and dignity, obtaining consent; handling complaints; staff training and record keeping.

The provider gave us an action plan on 6 February 2015 but did not provide timescales by which the regulations would be met. The provider did not send us the updates we requested in relation to progress they had made.

At this inspection we found that some improvements had been made but the provider had not completed all the actions they told us they would take. In particular they had not met the requirements of the warning notices we issued at out last inspection. As a result, they were breaching regulations relating to fundamental standards of care.

Some people made complimentary comments about the service they received. People told us they felt safe and well looked after. However, our own observations and the records we looked at did not always match the positive descriptions people had given us. Most of the relatives who we spoke with during our visit were satisfied with the service.

Effective systems were not in place to enable the provider to assess, monitor and improve the quality and safety of the service. The provider was not aware of some incidents of abuse and had therefore not notified these to the relevant authorities to make sure people were protected from the risk of abuse.

Risks to people’s safety and wellbeing were not always managed effectively to make sure they were protected from harm. The provider had not arranged for a fire safety risk assessment to be carried out by a suitably qualified person to make sure people were protected from the risk of fire.

People were not always provided with enough to eat and drink. One person had experienced significant weight loss. Action had not been taken in a timely manner to ensure they were protected them from malnutrition. People were not offered choice at mealtimes in ways they could understand.

Some people had not received their medicines as prescribed. Suitable arrangements were in place for managing medicines, but the recording of some medicines did not follow guidance issued by the National Institute for Health and Clinical Excellence.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider had not submitted Deprivation of Liberty Safeguards (DoLS) applications for most people, although they were aware of the requirement to do so. People’s mental capacity had not been assessed before decisions were made on their behalf.

The provider did not have an effective system to assess how many staff were required to meet people’s needs and to arrange for enough staff to be on duty at all times. We observed that there were not enough staff deployed to care for people effectively.

Staff had not received training in managing people’s behaviours that had a negative effect on themselves or others. Staff had not been trained in privacy and dignity or how to meet some people’s specific needs.

The complaints procedure was out of date and did not provide information about external authorities people could talk to if they were unhappy about the service. People told us they would speak to staff or the provider. We have made a recommendation about this.

People were not always involved in planning their care and their spiritual needs were not taken into account. We have made a recommendation about this.

People were not always provided with personalised care. They were not provided with sufficient, meaningful activities to promote their wellbeing.

Staff were cheerful and patient in their approach and had a good rapport with people. The atmosphere in the home was generally calm and relaxed and there were lots of smiles and laughter.

People were supported to maintain their relationships with people who mattered to them. Visitors were welcomed at the service at any reasonable time and were complimentary about the care their relatives received. People were consulted through resident’s and relative’s meetings and their views taken into account in the way the service was run.

Most staff had received the essential training and updates required, such as food hygiene and fire safety training, to meet people’s needs.

People were generally complimentary about the food and drinks were readily available throughout the day.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

Ensure that providers found to be providing inadequate care significantly improve

Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

You can see what action we told the provider to take at the back of the full version of this report.