Clare Mount care home, on Rochdale Road in Middleton, has been graded ‘requires improvement’ in all areas, except for the well-led assessment, in which it was rated ‘inadequate’.
The inspection is the latest in a string of reports that have found improvements were needed in areas of the service.
In the last three reports before this one, the leadership has been an area requiring improvement.
This is the second report to rate the leadership as inadequate.
The most recent report was published on June 6, following an inspection on January 20, when the service was caring for 18 people, most of whom were living with dementia and other cognitive impairments.
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The inspection was carried out to follow up on warning notices issued to both the provider and the registered manager at the last inspection, the CQC said.
It found that the service remained in breach of four regulations and that enough improvements had not been made.
The CQC said: “The provider had failed to ensure they consistently provided safe care and treatment, person-centred care, that they met the requirements for the need for consent and overall governance of the service.
“Medicines were not always managed safely, people’s risks were not always mitigated, the home environment was not always clean and safe, consent to care and treatment was not always in place, people did not always receive person-centred care to meet their individual needs and the home did not have effective governance systems to monitor and improve the quality and safety of the service.
“Clare Mount has now been rated requires improvement or inadequate for the last five inspections.
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“This meant there was a history of failing to respond effectively to serious concerns raised by CQC or other stakeholders.”
The healthcare regulator explained that despite its findings, feedback from residents and their families was mostly positive.
People said they felt supported by staff and felt safe, and that staff were kind and caring.
The CQC explained that this feedback was also echoed by the relatives of those living in the home.
In the assessment section ‘safe’, the CQC found that staff did not always listen to concerns about safety, and did not always investigate and report safety events.
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The report said the inspectors were not reassured that referrals to other healthcare providers were made in a ‘timely and appropriate’ manner.
Inspectors said that they saw some people had telephone hospital appointments, but did not see any support during this.
The CQC also said it found a letter confirming diagnosis of a terminal illness, but that this was not present in any care records for the person.
It also said the service did not always follow recommendations to purchase equipment to enable safe and effective end-of-life care.
In the ‘well-led’ assessment area, the home was rated ‘inadequate’.
The CQC said: “We were not assured the registered manager was always present at the home and fully involved with the running of the home.
“Information was not always readily available when we requested it.
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“We made one safeguarding referral to the local authority relating to allegations made by one person living at the home and their isolated status.
“Actions were taken by the social worker to make improvements to their quality of life as a result of the safeguarding referral.
“However, the concerns we raised had not been identified and acted upon prior to our inspection.
“We were not assured that all safeguarding concerns were reported, as is a requirement of registration, as we had not been notified of 2 previous concerns raised by the palliative care team.
“We found continued concerns with the storage of confidential information; care records containing confidential records, including medical information, were stored in the staff locker room, and this door was open and accessible throughout the inspection visits.”
The report said that people did not always feel they could speak up and have their voice heard.
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During the inspection, the CQC received anonymous whistleblowing concerns about the treatment of staff, but said that staff raised no concerns during site visits.
The CQC said that the provider did not always focus on continuous learning and improvement across the organisation.
The report said: “Although feedback from the local authority was positive, we found continuing concerns relating to the provision of care delivery and how people experience their day-to-day living at Clare Mount.
“We were not assured that people’s risks were competently assessed and monitored, and that learning from previous incidents was effectively and safely managed.
“We did not see evidence of a robust system in place to ensure the effective review of safety concerns, incidents and safeguarding concerns.
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“We were not assured that all incidents were reported and addressed appropriately.
“We were not assured that previous concerns identified and raised led to continuous improvement and learning shared across the home.
“This placed people at the risk of harm and we were not assured people were always safe and receiving good quality, effective care.”
The Oldham Times attempted to contact Clare Mount care home and the care management company, Rose Petals Health Care Ltd, but could not get through on the number provided.