Mountside Care Home

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 Requires Improvement. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
Staff spoke to us about the vision and culture of the service. Staff said that the management team were approachable and keen to listen, and that they feel well supported. They said that things had improved after a difficult few months and felt the home was going in a good direction. The registered manager and staff understood and supported people’s (and staffs’) cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team knew people well and worked alongside staff to support and promote good practice. All the staff were positive and proud of the care delivered to people they supported.
Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff described the in-house management team as visible, approachable and supportive. They said, “Visible and helpful,” and “They share with us and our residents about changes happening, also were very honest about recent safeguarding and what we need to do to improve, which we have done.”

The senior management team was committed to improvement and was open and transparent about improvements already made and those that were ongoing. We were told that the service focused on ensuring people were safe and happy and that learning was used to support further improvement.

There were systems and processes in place to support staff development and progression within their roles. Staff described how they were supported to gain qualifications and consider extending their roles. Senior care staff were supported to become medicine givers and received appropriate support and training. Staff received regular supervision, including values-based supervision, alongside spot checks and competency assessments. The provider’s senior management team visited the home regularly and provided support and supervision to the registered manager. The registered manager confirmed that she attended organisational management meetings, which enabled learning to be shared across the organisation and relevant lessons to be implemented within the home. The provider supported staff to attend external training and conferences and to network with other providers and managers through various forums.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us that they felt able to raise concerns. One staff member said, “I feel that I could voice any concern, we can do it anonymously if we want to,” and “We are all reminded at meetings and supervisions of safeguarding procedures, raising concerns and whistleblowing options.”

The provider and manager understood their responsibilities under the duty of candour. The duty of candour requires providers to be open and honest when untoward events occur.

We received notifications as required. During our assessment we found that the management team were open and transparent. They acknowledged when things had gone wrong and demonstrated the work they had undertaken in response to make improvements.

Staff felt able to voice their views and concerns. They were aware of the whistleblowing policy and felt able to raise concerns and be listened to. The provider had up-to-date whistleblowing policies and procedures which were in line with current guidance. People and their relatives confirmed they knew how to complain, and a copy of the complaints policy was available in the home and on the service website. Relatives told us they would make a complaint if necessary but would speak with staff first. The service maintained a record of complaints, including details of each complaint and the response provided. We saw that complaints had been responded to and action taken as necessary.

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.

Mental health and wellbeing of staff were regularly discussed to ensure that staff were confident and comfortable in their role. Staff confirmed that their supervisions always included asking about their health and well-being. The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required. There were robust measures in place to monitor, maintain and promote good mental well-being across the staff group. There were a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

The home was proud to be inclusive and supported both staff and people that used the service. The manager said the staff team was multicultural and everyone was respectful of each other.
Staff felt they were treated as individuals and their needs were taken into consideration, such as shift times being re-arranged to fit in with family commitments if required.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Quality assurance systems were in place and were used effectively to improve the service. The management team had worked hard to ensure there was robust oversight and effective governance at the service. There were computerised systems and processes to assess, monitor and improve the quality and safety of the service provided. Governance meetings were held regularly and minuted. These were used to monitor effectively and pick up trends/concerns early. The management team were aware of improvements needed and improvements that were on-going.

Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement.

The provider understood their duty to collaborate and work in partnership to ensure services worked seamlessly for people. They shared information and learning with partners and collaborated to support improvement. This included working with advocates, physiotherapists, chiropodists and hairdressers. One external stakeholder told us, “I have no concerns regarding the service, a manager or a senior will always greet me, to answer any queries and to give me accurate update on my clients.”

Staff said they had good relationships with other health professionals, and one staff member told us, “We work together to get good outcomes for people.”

The registered manager and provider were proactive in building relationships with other organisations and within the local community to improve outcomes for people.

Health professionals told us they had a good relationship with the service and that staff worked with them in a professional and knowledgeable way.

External performers were booked to entertain people, which were appreciated by people and their families. At residents’ meetings, activities were discussed, and people’s comments were noted and acted upon.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of promoting equality in people’s experiences, outcomes and quality of life. They actively contributed to safe and effective practice and research.

People and their relatives had opportunities to share their views about the service and the quality of care they received. People and their relatives described the staff and management team as open and approachable. Staff supported people to provide feedback, which was used to drive improvements and promote learning from incidents.

The provider and registered manager maintained oversight of accidents and incidents. They identified and addressed trends and patterns. We saw examples of lessons learned following incidents within the service, including the introduction of crash mats and sensor alarms where appropriate.

Reflective meetings provided staff with opportunities to discuss areas for development and improve their practice. Where appropriate, learning was also shared across the provider’s other services. The registered manager encouraged staff to speak up and share ideas for improvement.