CQC inspectors had to step in and help fall victim at Ipswich Monmouth Court Nursing Home

Monmouth court care home. Ipswich

Monmouth court care home. Ipswich

Inspectors had to assist a care home resident as she fell against a wall, despite workers being in the area, a shock health watchdog report has revealed.

Monmouth Court Nursing Home in Ipswich was inspected by the Care Quality Commission in December, with the damning report published last week rating the home inadequate in all areas and inspectors describing the home as “not safe.”

The ailing Bupa-run care home, in Monmouth Close, provides care for 153 people – including those with dementia and complex needs.

The report identified a number of worrying incidents in just two days, including one resident who had fallen over 59 times in just 10 months and a resident who fell over in the presence of inspectors, with staff failing to come to her aid.

Another resident went missing for 30 minutes before staff noticed, and it was found that staff were continuing to spoonfeed residents before they had even finished the previous mouthful.


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Residents at risk of malnutrition were missing out on meals as a result of difficulties eating and falling asleep.

The report said that: “Residents raised concerns about people’s safety,” and “People were put at risk of harm because care records and assessments did not clearly reflect all current areas of risk and how these should be managed to protect the person from harm.”

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CQC inspectors also raised concerns over the lack of staff considered to be suitably trained, practices for providing medication and a lack of support for residents. The report added: “We identified such serious concerns that we immediately fed these back to the registered manager so action could be taken to protect people from harm.”

One relative quoted in the report said their family member had regularly fallen over with no staff around to help.

The report continued that inspectors were forced to intervene when one resident, whose care plan stated she required a walking aid but had not been encouraged to do so by care staff, fell against a wall.

But bosses at the troubled care home – the third Bupa-run home in Suffolk and second in Ipswich to be rated inadequate this year – have said that immediate changes were made following the inspection and that resident welfare is “a top priority.”

A spokesman from the home said: “We took immediate action last year to address issues raised by the CQC. Our staff are undergoing a robust training programme tailored to our residents’ needs. As part of this, attention is being given to key focus areas such as meal times and we are ensuring strict procedures are being used in the delivery and recording of medicines.

“We are also building on our regular residents and relatives meetings by rolling out a ‘you said, we did’ policy, allowing everyone in the home to see how we are quickly responding to any questions or concerns.

“The health and wellbeing of our residents is our top priority.”

In light of the visit, inspectors have stopped all new admissions and informed safeguarding services at Suffolk County Council.

It is not yet clear what action the council will take.

Case study: Inspectors come to the aid of a resident

The report highlighted that inspectors were forced to intervene when one resident fell against a wall as a result of not having a walking aid – despite her care plan stating she should have one.

“We had to intervene during the inspection when the person became unsteady and fell against the wall,” the report said. “There were several members of care staff in the vicinity who did not come to the person’s aid, so we supported the person to steady themselves.

“A staff member brought their walking aid over, but placed the aid the wrong way round and left without speaking to the person. The person then walked off without the walking aid, and neither the staff nor the unit manager made any attempt to remind the person or change the aids position, leaving the person at a continued risk of falling and seriously injuring themselves.”

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