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 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 71 (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.

Since our previous assessment staff meetings were arranged more frequently. Minutes showed these were an opportunity to share any changes to how the service was operated. Staff and relatives referred to the ‘family and small’ nature of the service. One member of staff told us this enabled them to provide person-centred care.

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.

At the time of the assessment the service was going through changes to leadership arrangements.
There was no registered manager and the previous manager had recently left the service. The service was being overseen by a temporary manager and a newly appointed deputy manager. Both were experienced and had the appropriate skills and knowledge to lead the service.
Staff told us the new managers were approachable and able to give advice and guidance when needed. One commented, “The home is more organised now. [New Manager] is very good, very approachable.” The provider was actively seeking to recruit a permanent manager.
 

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

People, relatives and staff had opportunities to express their views through meetings and surveys.
People and relatives told us they felt comfortable raising any issues and were confident they would be listened to. We observed 1 person had a concern they wished to discuss. A member of staff sat quietly with them and allowed them to talk about their worries. They offered effective reassurance and support.

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 told us they were treated fairly and felt valued and supported. No staff reported any incidents of discrimination.

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.

Care plans now contained clear information on how to support people when they were distressed. Risk assessments were completed when required. Systems to oversee the management of people’s personal money had been strengthened. The provider had notified CQC of events as required by law.
The newly appointed deputy manager had responsibility for updating the auditing processes. They had created an audit schedule to help ensure all aspects of the service were regularly checked. Audit processes had been strengthened to minimise the risk of any gaps or areas for improvement being overlooked. For example, an equipment audit had been broken down into separate audits for specific equipment such as hoists and wheelchairs.
While progress was being made, there remained areas for improvement relating to recruitment and the implementation of the MCA. Please see the safe section of this report for details.

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 had worked with relatives and health professionals to help ensure care was provided in line with people’s wishes and preferences. Relatives told us they were kept up to date of any changes in their family members physical and emotional health.

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.

Staff file audits had failed to highlight the gaps found at assessment. Although managers were implementing systems to monitor the service’s performance, further time was needed to embed the changes.
However, the provider had demonstrated a commitment to driving improvement and had made positive changes to the service’s systems and processes. Feedback provided during this assessment was listened to and acted on in a positive and proactive way.