Mount Olivet Nursing Home

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

Safe- this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment in 2023 we rated this key question requires improvement. At this assessment we found improvements had been made and the service was no longer in breach of regulations in relation to safe care and treatment. We assessed all of the quality statements within this key question and have found at this assessment, the rating for this key question has improved to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives we spoke with did not highlight any concerns with the learning culture at the service. People and their relatives told us they would raise concerns with the registered manager. One relative told us “I would go to (registered manager name), the home is well managed”.

Staff told us how they were kept up to date when something went wrong. A staff member told us, “If something goes wrong, it depends on what it is, (registered manager name) may give a group supervision with us and we have taken part in them before, we are told what to be aware of and what we need to keep on top of.”

The registered manager had systems and processes to record incidents and accidents which were reported by staff. Where people needed professional advice following an incident or accident, this had been arranged as appropriate. The registered manager reviewed incidents to identify trends and themes and where actions to prevent reoccurrence were needed.

People we spoke with did not raise any concerns related to safe systems, pathways and transitions. It was clear from care plan reviews and speaking to people living at the service, they were able to see a range of healthcare professionals when they needed to. Peoples care plans, recorded if the person wished to be admitted to hospital or not, following their Treatment escalation plan.

The registered manager told us they work closely with the local authority to ensure people moving into the service have a safe transition. They told us they ask questions to people who had been providing care to the person being admitted, to ensure they were able to meet their needs.

Health professionals made positive comments about working with the service and told us when information was requested, the registered manager was responsive and easy to contact.

We identified the service did not always have a robust process to assess and document people’s needs and requirements before they moved into the service. We discussed this with the registered manager and provider who told us they had this documentation before COVID, however, after COVID did not always use that record. Following the assessment, the registered manager told us they had reinstated their processes to ensure people are thoroughly assessed and their needs have been recorded before being admitted to the service.

People and their relatives told us they felt safe at the service. One person told us, “I was a bit nervous at first, but I do feel safe here,” and another person told us, “I feel safe, everyone is always very kind and the manager is lovely.”

Staff were aware of their safeguarding responsibilities and were able to give us examples of situations they would report and the process of who they would report to. One staff member told us, “I would go to the senior carer and if nothing happened you would go to the manager and then (managing director’s name) and then if nothing still happened you would go to the safeguarding team.”

Staff were observed to be treating people with dignity and respect.

The service had systems and processes to monitor the safety of the service. The service had a Safeguarding vulnerable adults and children policy , it was up-to-date and regularly reviewed. The registered manager had raised concerns where needed to the local authority for example, where abuse was suspected. We found the registered manager had failed to notify CQC of an allegation of abuse and 2 approved Deprivation of Liberty Safeguards (DoLS) applications to restrict people of their liberty. We asked the registered manager to submit these notifications to us retrospectively. However, the registered manager failed to submit the notification of the allegation of abuse. This contributes to the breach in the regulation related to good governance.

People we spoke with could not tell us about their involvement with their care planning however, they were aware staff kept information about them to understand the person’s care needs. A relative told us “They asked lots of questions before (person’s name) came here, and they keep me updated all the time.”

Staff were aware of potential risks that may cause harm to people. Staff knew people well and understood when people required support to reduce risk to skin, dehydration and malnourishment. One staff member told us, “We have time to sit with people. We have (person’s name), sometimes it can be 45 mins to an hour to give them food and fluid and there is never any rush, you take as long as you need to ensure (person’s name) has food and drink.”

We observed and the registered manager told us, about measures they had put in place to ensure people were safe from avoidable harm. For example, the registered manager had recently identified the need to introduce a locked door policy for a short period of time. However, we identified that one area in the building had not been recognised or assessed as a risk and potentially placed people at risk of harm. We discussed this with the registered manager who acted immediately and risk assessed the concern ensuring the risk was minimised, to keep people safe from leaving the service without staff being aware.

The registered manager had systems and processes to monitor the quality and safety of the service. People had care plans which included known risks to the people and these records were reviewed. For example, in relation to care plan reviews being effective, as described in the delivering evidence-based care and treatment quality statement in the effective key question. At the last inspection, the service was in breach of regulations as the provider could not be assured risks to people’s skin were being mitigated which meant they were at risk from avoidable harm. At this assessment, the service had improved monitoring of repositioning and ensuring wound care plans contained sufficient guidance, which meant that people were now protected from harm.

People told us the service was clean and tidy. One person told us “It’s always kept clean, they work really hard making sure it’s clean and tidy.”

Staff told us there are weekly fire alarm tests and regular drills, they also told us they completed fire training, records confirmed this.

We saw a risk to the safety of the service which had not been identified, this put people at risk of possibly falling from a height. The provider told us they were aware of this risk, However, there was no evidence of this being assessed. On the day of the onsite assessment, the service completed a risk assessment which identified and mitigated the risk of people falling from a height.

The provider had policies to ensure the environment was safe and well-maintained. Fire safety was well managed, with regular fire drills and routine alarm tests. The provider had a business continuity plan and each person had a Personal Emergency Evacuation Plan (PEEP) which contained information about how best to support them during an evacuation.

Most people told us there were enough staff. Comments from people included, “I am well looked after. When I ring, they are here very quickly” and “Yes, there are enough.”

Staff told us they enjoyed working at Mount Olivet. One staff member told “It is great, that is why I have been working here so long.” Another told us “I think we are very lucky here, there is always staff and if anyone goes sick there is always someone willing to come in and cover their shift and we do a bit of everything tomorrow I am covering laundry, we all help each other when needed and I think that is why I have stayed this long because of the team.” They also told us about the training they had been provided with and how they felt confident raising concerns to the registered manager. The registered manager told us about new staff inductions and how their induction process had recently been adapted to include an annual refresher. A member a staff was now responsible for the induction process in their role as an induction champion. These changes were implemented following staff feedback. The recruitment records we reviewed had induction documents on file.

We observed enough staff were visible throughout the day and people were attended to in a timely way.

Staff were recruited safely, and recruitment records reflected this. The service had procedures to ensure the required checks were carried out on staff before they started work at Mount Olivet. This included enhanced Disclosure and Barring Service (DBS) checks for adults and reference checks. Staff training was provided and the service had a training matrix identifying who needed to complete training or receive refresher training.

People told us the service was clean and tidy. One person told us, “My room is nice and clean” and another person said, “Staff always wear gloves when supporting me.” A relative told us “Very impressed they clean (person’s name) room every day and she is always wearing clean clothes.”

Staff told us about the colour coding system the service had to minimise the risk of cross-contamination. They also informed us about the different training they had completed.

We observed the environment was tidy, clean, well-maintained and free from offensive odours. Rooms were personalised and bedding looked freshly laundered.

The registered manager completed regular audits of infection control at the service. The registered manager had national guidance available and local professional contacts to escalate any infectious diseases. The service had been awarded a “4 good” Food Hygiene Rating by the Food Standards Agency on 15 February 2024.

People and relatives told us the nurses manage people’s medicines and did not highlight any concerns. A relative told us, “The nurses manage all (person’s name) medicines, they speak with the GP if needed and keep me updated.”

Staff told us about how people would take their medication, this included how people would take medicines covertly (hidden in foods) when they needed to. Where this was happening, records confirmed approval had been sought from their medical professional in line with the requirements of the Mental Capacity Act 2005.

The registered manager had effective systems to ensure medicines were being administered, recorded, monitored and stored safely. Monthly medicines audits were completed to ensure people’s prescribed medicines were being administered in line with their prescriptions.