Mulgrave House Nursing 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. This is the first assessment for this newly registered service. This key question has been rated 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 care. The provider was in breach of regulation in relation to good governance.

This service scored 50 (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. Most staff told us communication from the registered manager could be improved. Comments from staff included, “I think improvement with communication is needed” and “I think [the registered manager] needs to be more involved with staff and passing the information over.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always demonstrate the skills and knowledge to support effective management and leadership. The registered manager had failed to provide consistently effective oversight of the service to ensure quality improvement. Feedback from staff regarding leaders was mixed comments included, “The registered manager needs to be more involved with staff members” and “What's not working well? communication, [the] manager working as a team” and “I think [the managers] are 3 strong characters if they worked as a team it would be marvellous.”

People did not always feel they could speak up and that their voice would be heard.Staff gave mixed feedback about speaking up and raising concerns. Most staff felt able to raise a concern however they felt they were not always listened to, and action was not always taken. Comments included, “I feel like I’m being listened to and then they go back and things slip” and “They are quite supportive, if you need support they are always there.”People and relatives said they knew who to speak with to address a concern. Comments included, “There’s an open afternoon on Tuesdays between 2 and 4 o’clock. It’s by appointment. I think if we wanted to speak to the [registered manager] another time, [they] would see me. We see [the registered manager] once in a while” and “I know the manager and can talk to her, if we needed to.”

The provider did not always value diversity in their workforce. They did not always work 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. However, staff gave mixed feedback and not all felt they were treated equally. Feedback included, “When I see how [Name] is treating other people, I am not happy with that.” Staff did not always have the opportunity to share ideas and influence practice improvement. Team meetings were not consistently held which limited the opportunities for staff to be involved in the development of the service. Most staff told us communication from the registered manager could be improved. The management team told us how they promoted workforce diversity and the well-being of staff. Staff however gave mixed feedback which included, “No bias or discrimination, I feel on the same level no higher or upper.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Governance systems in place had not always been effectively implemented to ensure robust oversight of risk and quality improvement. For example, audits relating to accidents and incidents had incorrect and inconsistent information recorded. This meant we could not be assured oversight was effective and risks to people mitigated. Concerns identified during the assessment had not been identified or addressed by the provider and registered manager, placing people at risk of harm. We identified regulatory breaches in relation to safe management of medicines 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 at the service impacted the effectiveness of collaborative working and sharing of accurate information.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Actions identified through quality checks and meetings were not consistently monitored to drive improvement. Where concerns were identified and recorded there was no evidence to support how these were tracked for compliance. Lessons were not always learned and when they were, they were not always shared with staff which meant the provider did not drive improvements.