Mont Calm Residential 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 Inadequate. At this assessment the rating has remained Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 36 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities. Whilst there had been some improvements since the last inspection, there still remained some care practices that were more for the benefit of staff rather than people. This related to people being woken by night staff before they went off duty in the morning and people not routinely being offered baths or showers. This could have been identified by leaders from the review of care notes. We also observed there were multiple notice boards around the service with guidance for staff including safeguarding information which could have been kept for the staff room. As a result, it made the service look less homely.

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. Whilst we saw there were staff meetings, these were not taking place regularly to gain valuable feedback from staff. This meant that not all staff had opportunities to feedback and be involved in the running of the service. During the assessment we identified multiple areas of concern with the safety of the environment (including the garden and furnishings) and infection control. Neither the provider nor the registered manager had identified these concerns from audits they had undertaken. For example, we saw from the April 2025 reports of the visits by the provider, they stated ‘The environment was clean, tidy, and free from obvious hazards.’ From a May 2025 visit report they stated, ‘The home is clean, comfortable, and well looked after.’ The registered managers audit of the June 2025 stated, ‘Furniture, carpets and equipment are well maintained and for purpose’.

People did not always feel they could speak up and that their voice would be heard. People did not always feel that if they expressed their views, they would be listened to. There were staff that said they would be comfortable speaking up but said they did not know how to do this. Other staff told us since the last assessment they felt at ease speaking up. One told us, “I feel comfortable in escalating concerns.” The registered manager told us, “I always open my door, and I go out and talk to staff members…staff are coming to us…. we remind staff members of the Whistle Blowing policy.”

Leaders did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. One member of staff fed back that they felt they were treated differently by the staff team. They told us, “I have to do things in a methodical way. If something changes it throws me. The managers are getting better at understanding, but the other carers aren’t.”

However, leaders would consider flexible working patterns for staff. They told us that since the last assessment, “When we do duty rota, we try to mix the staff team but don’t overlook skills as long as it’s not hindering care. Other staff members had issues travelling to work, so we made their shifts more flexible.”

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, or share this securely with others when appropriate. Whist we found there had been some improvements since the last assessment; these were not sufficient to ensure that people lived in a service that was well maintained, adhered to good infection control and care was always person-centred. We saw from an audit undertaken by an external consultant in February 2025 it was recommended that a section of a frayed carpet, was a trip hazard was not secured safely. At this assessment, whilst this section had been secured, there were other areas of carpet that were frayed and were a trip hazard. This had not been identified and addressed by leaders.The consultant’s findings were also that additional easy ready and dementia friendly signage should be implemented. This had not been fully addressed

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. Whilst we saw leaders consulted external professionals in relation to people’s health needs, more work was needed to ensure that the service environment met the needs of people living with dementia by consulting professionals in this area of expertise. We observed people walking with purpose around the service and there still lacked any meaningful areas of interest for them to interact with.

However, the registered manager told us had meetings with the registered manager of the provider’s other service to share ideas about improvements. They told they also attended the registered managers forum and, “You get to talk to other people (managers) as well and get to share their experience, get their skills.”

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. At the previous assessment we found multiple concerns in relation to person centred care including people not having opportunities to have bath and showers when they wanted. We did not see sufficient improvements in this area and although people may decline personal care, there was a lack of looking at creative ways staff could encourage this with people living with dementia. There still remained a lack reviewing the deployment of staff at night to reduce the risk of falls and incidents. Meaningful activities for people were still lacking, and leaders had not looked at creative ways people could participate in things they enjoyed doing.