Mount Vernon Terrace

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

People and those important to them were not fully supported to understand safeguarding and how to raise concerns when they didn’t feel safe. When concerns had been raised, the management team had not always promptly reported these to the relevant agencies to make sure timely action was taken to safeguard people from further risk. Staff understood their duty to protect people from abuse and knew how and when to report any concerns they had to the management team. There were enough staff to support people with their needs, although we observed staff did not always interact with people in a meaningful way. Staff were focussed on tasks and some staff were allocated to support people for a 12 hour shift on a one-to-one basis. This left people and staff without a quality experience during this time as some staff exhibited compassion fatigue. Safety risks to people were not effectively managed. Managers had assessed and reviewed safety risks to people but the plans in place lacked robustness. People and those important to them, were not always fully involved in making decisions about how they wished to be supported to stay safe. Managers reviewed staffing levels regularly to make sure there were always enough on duty. However, we found some staff lacked a good understanding of specific areas of people’s care needs. Not all staff had signed people’s care plans and risk assessment to acknowledge they had read and understood them. This had not been identified as a shortfall in audits completed by the management team. Staff received relevant training to meet the range of people’s needs at the service. However, the competency checks in place to support their continuous learning had failed to identify gaps in skills. The service was in breach of legal regulation in relation to people's safe care and treatment as they failed to assess and mitigate the risks relating to the health safety and welfare of people.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some people we spoke with felt unable to speak up if they had a concern. One person expressed feelings about not feeling safe or supported at all times, and not receiving their one-to-one support from staff when they should do. Another person felt that the service could be more responsive to their needs and told us, “I feel the support staff ignore me each and every day and the staff only interact with me when my behaviour becomes troublesome.” Other people felt improvements would be made to their care if needed. One person told us, “If I wanted to raise any concerns, I would ask to speak with the manager they would sort my concerns out within 24 hours.” Whilst another person said, “I feel the staff are caring and talk with me in general about anything. I feel they provide professional care.”

Staff had received regular supervision sessions to review what was working well, and to identify areas where their practice and resilience could be improved. However, we saw actions from these sessions had not always been followed up to enhance staff skills and learning from incidents. Staff gave examples of how the team had learnt from incidents. For example, the director explained, “We carry out regular supervision with all staff, which includes discussions around safeguarding incidents and their role in ensuring residents’ safety.” In regard to training provision at the service, one staff member told us,” We have loads of training and management prompt us to complete it. Right now, we are ok with what we have.”

There were processes in place for the management team and staff to review incidents. Staff meetings and individual supervision sessions allowed staff to reflect on what was working well, and what could be improved at the service. We found however, the debrief sessions after an incident had not led to actions being taken to improve care outcomes for people. There were no clear actions described as to how the reflective tool was used to support people in a positive way moving forward. This meant the tools used were ineffective and did not ensure improvements could be made or learning could be shared widely across the staff team. There was a provider policy for the duty of candour. This policy guided the service to tell the person (or, where appropriate their advocate) when something has gone wrong. We reviewed complaints that had been made and saw this policy had been followed by the management team.

People told us that communication between the care home and external health and social care teams was acceptable but could be improved; to ensure positive experiences and safe transition from other services. One person said, “I have never been involved in my care planning and have not seen the care plan.” Another person told us, “I had a care plan when I arrived at Mount Vernon Terrace, this was discussed with me to see if this met my care needs or if anything needed adding to provide me with the right care. My relative was involved when this was discussed with me.”

Although some staff showed a good knowledge of which health and social care professionals supported each person, we found some people living at Mount Vernon Terrace had not been reviewed by external teams when their needs had changed. We found some people who required external review for their specific needs had not been promptly referred by the service when concerns had been identified or after a specific incident had taken place. For example, after sustaining an injury following a fall or when people had expressed distress behaviours towards themselves or others. Care plan and risk assessments for people showed the review dates had lapsed. This left people exposed to a risk of harm, as there was no robust oversight or monitoring of people’s health conditions, to ensure timely referrals were made to other services. For example, where people were being supported by an external health care team for support with a mental health need.

Partners told us the service had been responsive to the concerns identified and the management team were working on implementing their recommendations. We saw the service had an action plan in place with the local authority to improve their safeguarding and documentation processes. These required embedding to ensure processes were clear, robust and protected people from the risk of harm.

Where people required external health and social care support, documentation showed that referrals had not always been made in a timely manner. For example, where people required input from an occupational therapist for review of bed rails or walking aids following a fall. Or where people required a review from a dietician or speech and language therapist for support with improving their food and nutrition management. Daily records lacked specific detail to enable clear oversight of people’s specific needs. For example, the daily monitoring sheet for people, which included details related to personal hygiene, food and fluid intake allowed for staff opinion, which created problems with the reliability of the records.

People told us they felt safe from abuse. All of the people who were able to communicate with us during our visit said they felt safe. One person told us, “I feel safe. At nighttime the doors are always locked within the home and the doors are alarmed, this makes me feel safe. I am happy with safety within the home.” People told us they felt no unlawful restrictions were imposed upon them. One person said, “I can choose what I want to do every day. I don’t have any restrictions staying at the home.” Another person said, “I am able to choose where I want to go and when, for example shopping and social activities.”

There was some understanding of safeguarding and how to take appropriate action, but safeguarding was not always given sufficient priority or applied consistently at Mount Vernon Terrace. We found the registered manager had not always made timely notifications to the local authority safeguarding team or the CQC to ensure that incidents could be promptly investigated. Not all staff we spoke with understood how to respond to allegations of abuse. One staff member struggled to explain the process in place for reporting concerns to the Local Authority or the CQC if the management team were not present. Staff we spoke with felt confident the management team would act appropriately if they raised concerns. One staff member told us, “The manager would contact the Local Authority for safeguarding issues.” When we asked staff about their confidence in raising safeguarding concerns; One staff member told us, “It depends on the issue, I would go via my manager.” Staff were confident in using whistleblowing processes if they felt concerns were not being responded to by the management team

We saw people and staff had positive relationships at Mount Vernon Terrace. There was an open culture of communication, and we saw no evidence that people were at risk or fearful of the staff team.

People were not always supported to understand safeguarding, what being safe meant to them, and how to raise concerns when they did not feel safe, or they had concerns about the safety of other people. Safeguarding systems, processes and practices were not always reliable or appropriate to keep people safe. Immediate action was not always taken to keep people safe from abuse and neglect. Safeguarding partners were not always worked with in a collaborative way. People were not always appropriately supported when they felt unsafe or experienced harm, abuse or neglect. There was limited understanding shown by the management team, of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We found the requirements of the MCA were not being consistently met and applied to ensure people’s rights were being upheld. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we found a lack of application of suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

People told us that they were able to communicate their needs, to receive the right type of support. One person said, “I am involved in my care planning every two months and informed if any things have been changed, I have seen a copy of my care plan but have not asked for a copy.” People told us that staff understood their needs well and offered support to keep them safe. One person told us, “The staff always ask me how I am feeling. If I am down, they will try and cheer me up and I have a good personal relationship with the staff.”

The director and registered manager showed empathy and understanding towards people, and staff appeared happy and relaxed in their presence. However, we found previous concerns had not been addressed to ensure risk management was robust and people’s risk individual risk assessments were updated. For example, where staff had been asked in supervision about specific needs of people and been unable to give a response. This had not been followed up by the management team. Staff had relevant received training on how to support people’s individual needs. Some people at the service could become distressed due to their mental health diagnoses. Staff had received training on how to support people when they became anxious or distressed, however, we saw this knowledge was not always being applied by the staff and management team.

On one occasion we observed a person exhibiting distress behaviours, who was not responded to promptly by staff. This placed the person and others at potential risk of harm. Staff were using techniques to de-escalate the situation, but these were not always being reviewed for their effectiveness. Debrief records we reviewed showed a lack of probing of incidents where people had placed themselves, others and staff at risk of potential harm. This meant people were not always kept safe from risk, as potential incidents were not analysed robustly to prevent reoccurrence. The management team could not show they had learned lessons and shared these with the staff team for embedding improvements moving forwards.

There was a lack of clear, individualised, processes in place for how to respond in an emergency. Each person had an individual Personal Emergency Evacuation Procedure in place (PEEP). However, we found these documents were inaccurate, in that some people had moved rooms, and the documents had not been updated with the new room number. One person had chosen to sleep on the floor of the communal lounge and this had not been identified as a risk to their wellbeing or indicated on their PEEP. We saw from supervision records that some staff had indicated they had no knowledge of the PEEP records for people. This left people exposed to the risk of harm in the event of a fire or other emergency. The director responded following our site visit on 29 October 2024, and provided updated copies of individual PEEP’s for people, along with a revised fire evacuation plan. We were assured by their response. People’s needs were clearly documented in their care plans, so staff had clear guidance on a person’s mental, physical and social needs. People’s communication needs were clearly recorded. This allowed staff to understand people’s needs and wishes and support them to stay safe.

People showed the inspection team their bedrooms. We saw people’s bedrooms had been personalised to their own tastes and included any equipment or adaptations to support their needs. However, we found the bedrooms we viewed to be in a poor state of repair and in need of refurbishment, with equipment which had not been regularly checked. This left people exposed to a risk of harm from the unsafe environment and equipment. We saw from records that people and the staff team had taken part in regular fire drills. However, the lack of wayfinding signage and poor lighting on the communal corridors would make exiting from the building in the event of an emergency a challenge for some people. The majority of people told us the call bells in their bedrooms were working and accessible. This meant they could request staff support if needed. One person told us, “I don’t have a call bell in my room.” Another person said, “The bedrooms have call buttons. If they are pressed the staff respond quickly for any support you need. I have had to press it once when I needed support getting out of bed, the staff did arrive quickly to provide me with support.”

Staff were not confident that the building was well maintained and refurbished to a high standard to ensure people were kept safe from the risk of harm. The director themselves explained how the building required significant refurbishment to ensure this was a safe place for people. We saw the directors had not invested in the environmental improvements needed since our last visit. The flooring throughout the service posed a risk to people living with mobility needs or a risk of falls. The service showed areas of significant disrepair, internal damp areas and was in need of decoration throughout. The management team had processes in place for monitoring the safety of the environment. For example, the management team documented their regular checks around the building. We saw that areas which had been identified, had not been promptly resolved to keep people safe. Staff knew how to respond in the event of an emergency evacuation. For example, if a fire alarm sounded, staff could explain where people would be supported to move to as the designated safe space. However, the overall fire safety risk management for the service lacked robustness and left people exposed to a risk of harm in the event of an emergency.

The home was not safe in the event of a fire. The management team had been served with an enforcement notice by Nottinghamshire Fire & Rescue Service on 18 October 2024. We saw minimal actions had been taken to achieve compliance with this. Corridors were narrow and not clear of all blockages, which would allow people to follow easy to read escape routes. Signage was challenging to read in corridors which had poor lighting. Some areas of the premises placed people at risk of injury, particularly those who were independently mobile. Wardrobes were not always attached to walls, bedroom furniture was damaged, and the toilet basins, cisterns and sinks in bathrooms were poorly maintained. Windows were able to be opened wide, due to the restrictors not being maintained. This safety feature should prevent people from falling or climbing out and is in line with guidance from the health and safety executive (HSE). The service was in a state of significant disrepair, meaning it was unsafe and unsanitary for people living there.

The environment was not being kept safe, by effective maintenance and refurbishment. Although we saw there had been regular checks to ensure the water quality was maintained and temperature checked to reduce the risk of water-borne bacteria (like legionella.) The gas heating system was regularly serviced to prevent harm to people. People had access to call bells to call for support if needed. Documentation showed these call bells were regularly checked and audited by the manager, to ensure they were working and effective. However, we found that some call bell alarms were not sited appropriately in people’s bedrooms, posing a risk that people would struggle to access this when they needed them. Electrical socket extension leads were overfilled, presenting a risk of fire and falls to people living with mobility needs. All of the above left people exposed to a risk of harm from the poorly maintained environment.

The majority of people and their visitors told us there were enough staff, and their needs were responded to. One person told us, “I feel there are enough staff on duty at all times including night shifts and weekends.” While another person said, “I feel the staff are good at their job and I think the staff are caring and understanding.”

Not all staff we spoke with could not explain how the service provided sufficient training for them to ensure they were skilled and knowledgeable in their roles. A staff member we spoke with struggled to explain the training they had completed to support people’s specific needs, and what extra training they would benefit from. Staff told us they had regular opportunities to meet their line manager on a one to one basis for supervision. These meetings gave them the opportunity to feedback about their experiences and request further guidance/training if needed. Staff we spoke with felt there were sufficient staff to support people with their identified needs. One staff member told us, “Yes, there are always enough staff.”

We saw the management team and staff were not always suitably trained to complete their roles. For example, when we asked staff to explain the principles of the Mental Capacity Act (2005) and implementing this to ensure people were not unnecessarily restricted. This left people exposed to the risk of being supported by staff who lacked an understanding of a person’s capacity to make decisions. We saw that staff used their understanding of people as individuals, to respond to people’s needs. One person we spoke with spoke positively about of the knowledge of the staff team, saying, “I feel the staff are capable of providing the care I need.”

We saw there were ongoing processes in place to assess staff competency. However, we raised concerns with the director around the competency assessments completed for medicines administration. Some staff we spoke with showed a lack of understanding of specific medicines and their potential impact on people’s well-being. The director agreed to review and improve the competency checks for staff moving forwards. Staff had received suitable training to do their role. However, the management team had not ensured there were always suitably skilled and knowledgeable staff working. If staff were not providing the expected level of care, there were processes in place to monitor and improve their performance.

People told us that the home was not always kept clean. One person said, “The home is not cleaned properly. The registered manager has told the support staff they need to ensure the home is adequately kept cleaned. There are some residents who leave the toilets and bathrooms unclean, and staff are aware this happens but never take any action when this is reported to them.”

Good infection prevention and control practice was not being made a priority at Mount Vernon Terrace. The management team had not considered the challenges that a poorly maintained environment had placed on the ability of the domestic team to ensure the service could be adequately deep cleaned. These significant shortfalls left people exposed to the risk of infection through poor infection prevention and control practices.

The service was unclean and unhygienic. Due to the lack of maintenance, the service was unable to be effectively deep cleaned to ensure people were protected from the risk of infection. The home was unsafe in the event of a fire. Corridors and flooring were not well maintained or kept clear of any blockages, this meant people could not easily follow fire evacuation escape routes. We saw the kitchen was managed in a hygienic way by a knowledgeable member of staff, to ensure people were not at risk of food borne infections. The most recent check from the food standards agency, had rated the service 4 stars in October 2023. Staff had received food hygiene training; they were able to explain what actions they took to reduce the risk of food borne infections

There was a lack of robust processes and policies in place, to ensure the environment was kept clean and hygienic. This placed people at risk of harm from the spread of infection. If an infection outbreak occurred (for example diarrhoea and vomiting), there was a lack of clear processes in place to reduce the risk of this spreading to other people at the service. For example, there was a lack of high touchpoint cleaning, which reduces the spread of infection on areas which are used the most by people, such as communal toilets, handrails on stairs and handles on doors. People were not encouraged to maintain their own personal cleanliness. We saw people who had ingrained, dirty fingernails, which presented an infection risk to themselves and others. Where people had been identified as being resistant to support with personal care, there was a lack of exploration by the management team to engage positively with people to encourage them to self-manage their daily personal care. Staff had received training in infection control, how to put on protective equipment and how to keep people safe in the event of an infection outbreak.

People told us that they were happy with the support from staff with their medicines. One person told us, “I am happy with my medication. The staff give me my medication on time.” People told us that staff gave their medicine at regular times, and as their prescription required. One person said, “I receive my medication with support from staff. I have no issues with this.” Another person said, “My medication is supported by the staff and my medication is always given on time.”

Staff were unable to fully explain how they supported people to take their medicines safely. One staff member we spoke with struggled to explain the possible side effects of specific medicines they were administering and the signs to look out for. Some staff lacked understanding of who to report medicine concerns or errors to. For example, if they felt a person’s medicine was no longer effective, there was a lack of documentation to support this. Information showing which health professionals had been involved in these decisions was not always transferred into a person’s care plan or medicines risk assessment. One staff member told us, “We do look out for side effects and contact the GP. One person was taking ‘as required’ medicine, but it was too much. We were aware and raised it with the GP. We know they don't usually behave that way.” Some people at the service were prescribed controlled drugs. These are subject to enhanced restrictions due to the addictive nature of these medicines. We saw staff had followed national legal requirements by storing these medicines in an extra secure place. However, the documentation for these medicines was poor, showing a lack of regular audits by the management team. Where medicines needed to be stored at a certain temperature, this had been done. For example, some people required their medicines to be stored in a fridge. Staff had checked the fridge temperature on a daily basis to ensure it was working as expected.

We found concerns with the accuracy of documentation for people requiring ‘as needed’ medicines. Where people were prescribed medicines like paracetamol for occasional pain relief, we found variable doses were not accurately recorded. This left people at risk of harm from receiving medicine which were not as prescribed. For example, one person required pain relief at a variable dosage due to a change in clinical needs. There was a lack of protocol in place to guide staff on symptoms they may show, effective dosage levels and impact on the person’s pain levels. We found a prescription for essential medicines for people had not been promptly requested when a medicine had run out. This left people exposed to the risk of harm. Some medicines administration records we reviewed showed unclear records when staff had given prescribed medicines. Errors had not been identified in audits completed by the management team. This was a significant shortfall, and left people exposed to the risk of harm through not receiving their medicines safely. Where people had repeatedly refused medicines, we saw a lack of urgency in contacting the prescriber for a review. Medicines care plans had not been read and signed by all staff to acknowledge their understanding of a person’s medicines regime and the potential impact of this on their well-being. This left people at risk of harm from staff who lacked knowledge and were unable to follow best practice guidance for administration of medicines. Staff received training on how to administer medicines safely. The management team completed assessments of staff’s competency. However, we found competency checks had not identified shortfalls we found or gaps in knowledge shown by staff around the impact of specific medicines. Staff completed regular stock checks of all medicines. However, we found errors in medicine’s reconciliation records and returns book. This meant management could not be assured suitable stock levels were always in place.