Mountjoy Road

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to good governance.

This service scored 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Shortfalls in effective leadership and governance at the service placed people at risk of receiving unsafe care. The provider had values in place however this was not reflected across all aspects of care provision. Whilst the registered manager and staff were kind and wanted to support people to lead fulfilling lives, the shortfalls in effective risk management, medicines management and care planning placed people at risk of harm.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not always do so with integrity, openness and honesty.

Provider level leaders and the registered manager did not demonstrate the skills and knowledge to support effective leadership. Both had failed to maintain effective oversight of the service to support good quality care delivery and standards. They failed to complete accurate and robust quality assurance checks. Quality assurance documents reviewed during the assessment showed missing and duplicated information. In addition, it was documented in audits that people’s care plans were in place when this was not the case.

Staff told us they had a good relationship with the registered manager and gave positive feedback. One staff member told us, “The registered manager is nice. Very co-operative. They listen” and “The registered manager is the best manager I’ve ever had.”

People felt they could speak up and their voice would be heard.

Staff felt confident and able to raise concerns with the registered manager. They felt they were listened to and supported. Systems and processes were in place to support speaking up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider employed a diverse workforce from varying backgrounds and cultures. Staff consistently told us they enjoyed working at the service and they were treated equally and fairly.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

Systems and processes were not in place or operated effectively to ensure effective oversight and quality improvement at the service. There was a lack of robust provider level and registered manager oversight. Quality assurance systems and processes had not identified or addressed concerns found during the assessment process. For example, concerns relating to risk assessment and management; record keeping and medicines management. We identified regulatory breaches in relation to medicines management and good governance.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

A lack of oversight and robust monitoring impacted the effectiveness of collaborative working and sharing of information to inform service improvement. Failures in governance systems meant concerns had not been identified and therefore could not be shared with partner organisations. The registered manager knew their responsibilities in relation to submitting notifications to the Local Authority and CQC.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system.

The provider and registered manager failed to maintain oversight, learn lessons and make changes to improve the service. Despite consistent leadership at both provider and service level, the assessment identified a breach of regulation relating to medicines management and good governance. This demonstrated a failure on behalf of the leadership team to identify concerns within the service, learn and sufficiently improve.