Moss Cottage 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 good. At this assessment the rating has changed to 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 61 (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 provider had an action plan and clear commitment to driving improvement. However, at the time of our visit, work was needed to ensure all key staff vacancies were filled including the role of the registered manager, in order to drive the improvement forward. The provider was working in the home to support the development of an open and transparent culture where any issues were identified and addressed. The provider spoke of some of the challenges with social care which included finding people suitable to the vacant positions.

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 have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

At the time of our inspection, there was no registered manager in post, and during the inspection the management arrangements changed. The provider advised that a new manager was due to start shortly after the inspection and would be applying to register with CQC. It is a condition of the provider's registration to have a registered manager in post to manage the home.

The provider had implemented interim arrangements, with members of the senior management team sharing responsibility for the management of the home. This was a stable management team whose members had been in post for a number of years and knew the service well.

The manager in post at the beginning of the inspection was generally well regarded by people and their families. The provider acknowledged that they had brought stability to the home and had contributed to improvements in both the culture and practice within the service.

Staff spoke positively about this manager and described feeling well supported. However, some staff expressed concerns about the number of changes in management and the impact this had on expectations, consistency, and ways of working within the home.

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

There were processes in place to raise concerns, including to whistle blow. Staff told us that they felt able to raise concerns and generally felt things would be addressed. Families commented that they felt able to raise concerns with one relative telling us, “I would speak with [home manager] if I wasn't happy. They have tried to resolve any issues that I’ve brought to them.”

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.

The home manager told us they had an open-door policy and would make reasonable adjustments to support the staff team in response to any changes in need. Staff told us they enjoyed their jobs and felt respected, valued, and supported within their roles.

Staff were encouraged to develop professionally, including completing National Vocational Qualifications and becoming champions for specific areas of care, such as dignity and dementia care. The provider was also in the process of sourcing enhanced training to further support staff undertaking champion roles and to strengthen practice in these specialist areas.

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.

The provider had a range of quality assurance systems and audits in place. While these were completed regularly, they had not always been effective in identifying some of the concerns found during this inspection.

The provider had an action plan in place and had already identified several areas requiring improvement, including care planning, care records, and aspects of the environment. They were responsive to the concerns raised during the inspection and took action to address these issues.

We will review the effectiveness of these actions, and how improvements have been embedded into practice, at our next assessment of the service.

The provider did not always understand their duty to collaborate and work in partnership to ensure services worked seamlessly for people. They did not always share information and learning with partners or collaborate effectively to drive improvement.

At the time of our inspection, there was limited involvement with the local community. The provider acknowledged that further work was needed to strengthen links within the community, including developing opportunities for intergenerational activities and building relationships with local faith groups and community organisations. One person told us, “I wanted to go to church on Sunday, but I'm not allowed out now. I don't think there are any church visits here to have services or to take communion.”

Some people were supported to access the local community with the support of their families. The provider recognised the potential benefits of increasing community engagement and was exploring ways to develop stronger partnerships that would enhance people's wellbeing, social connections, and opportunities for meaningful participation.

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 home had an action plan in place which covered some of our concerns in relation to the environment and care planning. However, not all of our concerns had been identified through the providers own systems.

At the time of our visit, further work was needed to ensure vacant posts were filled with suitably skilled and experienced staff. This included key leadership roles, where vacancies had impacted the provider's ability to drive and sustain improvements. The provider was actively recruiting to these positions and recognised the importance of having a stable and consistent management and staff team in place to support ongoing service development.