Archived: The Mount 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 1 legal regulation in relation to inadequate 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.

The staff we spoke with did not know what the vision or strategy of the home was. The staff were unable to share with us what the shared values were. Due to the lack of consistent leadership and direction the culture was not based on the promotion of learning and improvement. There had been a lack of consistent staff meetings, supervisions and observations of staff practices to ensure staff received the support and feedback about their performance to help drive improvements in the home.

Reviews of people’s care plans had not ensured a fully inclusive and collaborative process of care plan development. The provider had not ensured staff had completed core, or specific training in accordance with people’s individual needs to promote equality, diversity, inclusion and engagement.

Staff told us they aimed to provide ‘good care’ and to treat people ‘fairly’. The staff had some understanding of what a closed culture was and told us they would report any concerns about poor practices.

The new manager recognised the impact the changes in management has had on the home. The new manager told us they hoped to bring some stability to the home. However, the new manager handed in their notice following our assessment.

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, and they did not do so with integrity, openness and honesty.

A new manager had commenced employment at the service a few weeks prior to our assessment. Before this the home did not have a manager for several months and a senior carer was managing the home in addition to supporting people. The provider visited daily; however, they failed to have the skills, knowledge and experience to provide support and guidance to the staff team. The provider failed to maintain oversight of the quality of care being provided and failed to monitor the performance of the previous managers. The provider failed to demonstrate they led by example with promoting inclusive behaviours.

The manager had completed their own internal audit when they first commenced employment to enable them to prioritise where immediate actions needed to be taken. They had developed an action plan and had begun planning supervisions and meetings with staff. The manager had called all relatives to introduce themselves. Relatives we spoke with knew who the manager was.

The provider and manager were receptive to our feedback and took some steps to immediately improve safety in the home following our daily feedback.

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

The provider had failed to adopt an inclusive approach in gathering regular feedback from people, relatives and staff to give them the opportunity to share any concerns they may have.

Some relatives told us they had shared feedback about the previous manager with the provider. However, this feedback had not been recorded, and the provider was unable to tell us what action they had taken to address the previous manager’s performance.

We received mixed feedback from staff about the previous manager. Some felt they could raise concerns but told us they doubted any action would be taken. Other staff did not think the previous manager was approachable and did not raise concerns, choosing to speak to their peers instead. Some staff felt able to share concerns with the provider but were not sure if any actions were taken in response to their comments. Other staff member told us they did not feel confident speaking up to the provider who was described by some staff as ‘not approachable’. The provider had failed to ensure details of concerns being raised had been recorded.

There were some records of staff meetings held in 2024 but where comments had been shared there were no actions recorded in response to these. Surveys had been sent out in 2024, but the responses had not been analysed, and no actions recorded in response to suggestions made to use this feedback to drive improvements within the service.

Staff told us they would speak with the new manager if they had any concerns. A staff member told us, “I feel confident to share concerns with [manager] they seem nice and approachable, and they know their stuff. This manager will be good for this home and hopefully will make the improvements needed.”

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 and previous management had failed to ensure staff had received regular training opportunities to safely fulfil their roles. Most of the training provided was online training and the expectation was for staff to complete this at home in their own time. There was a lack of oversight and monitoring of training completed by staff or consideration of any adjustments that may have been needed to how training was delivered to reflect staff diverse needs. Most of the staff team had completed equality and diversity training. However, there was limited evidence to support if staff knowledge and skills had been assessed following learning to check their understanding and how this had been applied in the service.

Staff told us they worked well together as a team and supported each other during the absence of management support. A staff member told us, “The morale is up and down here due to the changes in management, so we get on with things and do our best for the people that live here. I love working here but at times it can be stressful. I am hopeful the new manager will stay so we have some stability.”

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.

The provider did not have an effective system or processes in place for the monitoring of the quality of care provided to drive improvements. The provider failed to support and maintain oversight to monitor the performance of managers in addressing previous and current shortfalls we found during this assessment. Since our last assessment the home has had 3 managers. None of these managers have successfully applied to become registered with CQC. Action plans had been sent to us which had been signed off by the provider. However, we found the information was inaccurate and did not reflect the risk within the home and the lack of actions being taken to address these. For example, we found inaccurate and unclear information in people's care plans and risk management plans; poor management of risks; poor oversight of potential risks in the care environment; poor support with nutrition and hydration; inconsistent support and recording in relation to people’s food and fluid intake, repositioning and safety checks; and a lack of analysis of incidents and accidents and the lack of recording of complaints. The provider's auditing and monitoring of people's care was ineffective.

The provider failed to carry out audits of staff recruitment files to ensure all checks had been completed and safe processes had been followed. The provider failed to monitor staff had completed training to ensure they were competent in their roles. The provider had failed to ensure their safeguarding processes to identify when people were at risk of abuse were robust. Where safeguarding concerns had been identified, the correct actions were not always taken, and concerns were not always reported to the appropriate authorities. We found the provider had failed to follow their own policies and procedures. This meant they were not always meeting the requirements of current legislation.

The provider had recruited a new manager who told us they felt ‘overwhelmed’ with the number of improvements needed to be made and the lack of systems in place. They had developed an action plan to start the process of addressing these. However, as previously stated this manager resigned from their role shortly after receiving verbal feedback following our assessment.

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.

People and relatives confirmed referrals had been made to health and social care professionals to gain support about people’s needs. However, recommendations made, and information shared was not always followed or accessible to staff. For example, information from speech and language assessments had not always been updated in people’s care records and therefore staff were not always following these, which placed some people at risk of harm. In addition, information shared by Mental Health professionals was not recorded detailing how risks to people should be supported. Actions from the West Midlands Fire Service had not been addressed in a timely manner to safeguard people, staff and visitors in the event of a fire. Recommendations and learning following a safeguarding enquiry were not shared with all staff and action taken to implement these in a timely way to mitigate future risks.

Feedback from partner agencies confirmed that although the provider worked in partnership with them, limited progress was made to implement recommendations shared.

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.

The provider had failed to learn lessons and make improvements following CQC assessments. At this assessment, and over the course of our previous inspections of the service, we have identified significant concerns in the safety and quality of people’s care, several of which represent repeated failings and breaches of regulations. There was a lack of robust systems and processes for assessing and monitoring the safety and quality of people’s care. The provider had failed to meet their legal requirements and demonstrate a commitment to drive the improvements in people’s care.