Mount Pleasant House

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 governance at the service.

This service scored 54 (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.

Opportunities for managers to share organisational values, expectations, and priorities with staff were limited.Staff meetings were held irregularly, reducing opportunities for collective learning, reflection, and engagement. Although records of meetings were available, minutes did not always capture sufficient detail,which limited leaders’ ability to demonstrate how feedback, risks, or actions were followed up and embedded into practice.

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.

Staff told us the acting manager was approachable and supportive, which helped them to raise concerns and discuss day‑to‑day issues. People’s relatives and representatives spoke positively about the acting manager, describing them as “helpful”. They told us changes were actioned when raised.

The acting manager told us they did not have a deputy manager or administrator to support them. As a result, managerial tasks were difficult to complete in a timely manner and the need to cover staff vacancies meant the acting manager had to work in the kitchen regularly.

The provider did not ensure the acting manager had additional training such as completing medication competency assessments for staff and assessing the mental capacity of people, to carry out their role effectively.

People did not always feel they could speak up and that their voice would be heard.

Staff spoke highly of the acting manager and the support they received. However, records of staff meetings failed to show how the provider invited staff to contribute or raise suggestions.

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.

There was no evidence of discrimination. Staff had received equality and diversity training.

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.

There was no registered manager at the time of the assessment.

The acting managertold us they were frequently required to cover staffing shortfalls,including providing direct care to people and working in the kitchen. They did not always have sufficient time to complete key managerial responsibilities,such as reviewing and updating care plans, completing audits, and monitoring quality and risks.

The provider told us they did not routinely oversee the service to ensure audits had been completedand instead relied on the acting manager to carry out these tasks.

The provider had not ensured policies were up to date and followed. The ‘quality management’ policy stated a ‘quality audit will be conducted on an annual basis’, this had not been completed. The acting manager had implemented different audits for ‘equipment, care planning and health and safety’. The acting manager told us they were behind on audits as they “did not have time” to complete all of them.

Care plan audits did not consistently detect missing or inaccurate information, including care plans for, malnutrition and behavioural needs. Risk assessments were generic, incomplete, or out of date, and records did not always reflect significant risks as around falls and people leaving the service unsupported.

Mental capacity assessments were not consistently completed when a person may lack the ability to make specific decisions. A Deprivation of Liberty Safeguards application had been made, however, no Mental Capacity Act assessment had been completed to inform this application. This had not been identified by the provider and meant people may not be supported to make decisions.

Record-keeping and documentation were inconsistent. Best interest decisions were incomplete or absent, and consent forms were expired or missing information. This meant people’s rights and preferences were not consistently respected.

The ‘service users' money and financial affairs management’ policy stated, ‘Written records of all transactions with service users should be maintained and kept securely’. The service heldmonies for people using the service, and money raised for residents. However, accurate records detailing monies received and transactions made were not maintained.

A staff file audit had been completed but did not record the date it was carried out. This audit highlighted recruitment checks had not been carried out and there was information missing, including references, application forms and interview notes. During our assessment these findings had not been addressed and there were gaps in the documentation.

Statutory notifications had not always been submitted to CQC in line with legal requirements. This included when a person had a Deprivation of Liberty Safeguards application approved.

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.

There were effective processes to ensure partnership working with people, relatives and health professionals was maintained to improve people's experiences, health, and wellbeing. The acting manager told us they worked closely with health professionals.

One healthcare professional told us the acting manager kept them up to date of any changes in a person’s condition and during the assessment we heard doctors were requested to visit when a person became unwell.

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.

The provider did not have a formal strategy for innovation or improvement, and it was unclear how outcomes were being measured or reviewed. Staff were engaged and provided care in a kind manner. However, systems for reflection, feedback and evaluation were needed to embed a consistent approach to learning and improvement.