Mount Elton 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 62 (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. The aims and objectives of the home were included in the provider’s statement of purpose, which was on display. People received a welcome pack with the home’s philosophy of care outlined. A person said, “They are fantastic. I’m staying here, I’m never leaving this home.” A relative said, “It is excellent, the staff are very attentive.” There was a friendly and happy atmosphere at the service and within the staff team. A person told us, “There is happiness everywhere, often people are singing.” Staff enjoyed working at the service and said there was a positive culture. A staff member said, “The staff team get on really well.”

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. There was a staffing structure with designated roles and responsibilities. Managers were approachable and supportive of staff. The registered manager completed additional training relevant to their role and engaged in local networks and forums. A person said, “The [registered] manager is very approachable, she visits everyone every day. A relative said, “I know the manager, I find them approachable.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Systems enabled staff to speak up including, supervisions and staff surveys. Staff meetings were held regularly. Staff told us they felt comfortable raising any areas for discussion.

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. Staff had completed equality training to support their understanding of protected characteristics and awareness of bullying and harassment. Staff told us they were fairly treated and worked within in a diverse team where they were respected.

The provider did not have clear systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this with others when appropriate. Allegation of abuse notifications had not been submitted to the Care Quality Commission (CQC) as required. Notifications are information about an event or person which the service is required to inform CQC about. Other notifications, for example, about deaths or deprivation of liberty authorisations had been sent as required. A range of management audits were conducted in areas such as medicines, health and safety and care planning. Audits had associated action plans for areas identified as requiring changes. However, governance systems had not identified areas found at this assessment. Such as safeguarding notifications not submitted as required, mental capacity assessment and associated best interest decision not completed for specific areas of care, fully following the provider’s complaints procedure and ensuring care plans contained person-centred information. There was a lack of structured provider oversight. The service did not have an improvement plan to demonstrate areas they had identified for development.Records and data were stored and managed confidentiality. The provider’s CQC assessment rating was displayed at the service as required. The service did not have a website.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The service worked in partnership with other professionals and had positive working relationships to support people with their quality of life and health. The service communicated information with people’s families. A relative said, “I am kept informed, they communicate with me.” Events were held where friends and family could join in and spend time. The home was part of the local community. A health and social care professional said, “The home is an extension of the community.”

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. Further development of governance systems was needed to enable the service to identify areas for improvement and innovation and manage development progress. This included consistent ways of measuring outcomes, impact and sharing of learning. For example, through safeguarding and complaint outcomes.

The service had considered people’s individual requirements and worked within the local system to provide equipment and experiences to meet those needs. For example, a senior staff member had worked to source an appropriate chair for someone. This enabled them to have time out of their bed. Another person had an electronic device set up at their table, so they could enjoy and engage in television programmes of their choice. Further development of governance systems was needed to enable the service to identify areas for improvement and innovation.