Mount Vernon Terrace

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment, this key question was rated requires improvement. At this assessment, the rating has improved to good. This meant the service was consistently managed and well-led. The management team and the culture they created promoted high-quality, person-centred care.

The provider was previously in breach of legal regulation in relation to the governance of the service. At this assessment we found significant improvements had been made, and the provider was no longer in breach of regulation.

There were clear and effective governance, management and accountability arrangements in place at Mount Vernon Terrace. Staff understood their roles and responsibilities. The management team were fully accountable for the actions, behaviours and performance of staff. The systems to manage current and future performance and risks to the quality of the service showed an improved, robust approach. Data or notifications had been consistently submitted to external organisations as required. There were robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care. The management team implemented recognised standards and best practices, to improve experiences and outcomes for the people living at the service.

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 management team had a service improvement plan in place to track developments and ensure the required measures were taken to improve the service to safe standard. The management team all had responsibility for ensuring these actions were completed. Where there were areas which were identified as still requiring completion, the directors gave their full commitment to ensuring these were actioned.

We saw the directors had significantly invested in the planned service improvements. The manager told us, “The directors have been happy to invest. They are very open and transparent. I have found them very welcoming.”

The management team had implemented improved systems to deliver a positive experience, and good quality of life for people. Any shortfalls identified in care quality, found at our previous inspection had been addressed. For example, there were improved audits in place to show when Mental Capacity assessments were completed, the outcomes of such assessments, and the dates when they should be reviewed.

Staff were effectively supported to share their views through regular, meaningful supervision sessions. These covered their own mental, emotional and physical wellbeing, along with areas where they wanted to progress or receive further training. One staff member told us, “The new manager shows a lot of love, they are calmer and offer more direction and support.”

The service 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.

The directors had given their full commitment to investing in improving the service, acknowledging previous shortfalls found. The service had plans in place to further improve the living environment for people with achievable planned completion dates in place. The director had a service improvement plan in place with a tracker for progress.

The management team had a positive working relationship with the staff team. Our observations of their interactions with people, professionals and staff during the site visit indicated they were committed to making the necessary improvements. The manager operated an open-door approach, being visible and available for people and staff. One person said, “I have a good relationship with the management team and all of the support staff at the home. I think the home provides good care. I cannot think of anything regarding further improvements.”

One person we spoke with gave positive feedback regarding the support the manager had given to them. They said, “I have been introduced to the new manager. I get on well with them. I can just knock on their door or ask staff to make arrangements to see them.”

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

The culture of the service had significantly improved, with people and staff who felt confident to share their views and feel heard. One staff member gave positive feedback about the management of the service, and their support. They told us, “Things have been so much better since the new manager has been here. They are kind, understanding and approachable, I feel like I can go to them for anything that I need.”

The provider valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

The service had an open and transparent, positive culture. The service employed staff from diverse backgrounds, some of whom were from overseas. The background and culture of people and staff was fully respected by the service. Staff were supported to progress in their chosen career.

Support staff we spoke with on the day of assessment explained they were really happy with the changes the management had made in a short time. Staff felt the training they had access to had been improved and they felt more confident in their roles to provide better quality care for people.

The management team 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.

The management team had a service improvement plan, business continuity plan and emergency plans in place. We found clear evidence of progress towards the stated outcomes. The director explained how they were committed to investment in the service and staff team to ensure future service development.

There were regular audits taking place of people’s care plans and daily records which meant the management team had effective oversight. The manager had completed regular spot checks, both during the day and on night shifts. Any actions they had identified were clearly recorded, so action could be taken to improve care quality.

The management team had ensured the governance systems and processes in place to manage risk were effective. Accident, incident and falls analysis was in place which was utilised to identify themes and trends. This in turn informed how they improved support and safety for people.

The management team showed evidence of using reflective practice to embed lessons learned. Improvements were being implemented as a result of incidents that had occurred. The management team ensured they were being open and transparent, by reporting all notifiable incidents to the Local Authority and the CQC as required by law.

The management team understood and carried out their duty to collaborate and worked in partnership, and services worked for people. They always shared information with partners and collaborated for improvement.

The management team had improved the way they worked in partnership with external partners. The management team explained how they had found the provider investigation procedure with the local authority to be a supportive process. They felt this multi-agency guidance had supported them to drive improvements to their governance systems. This had enabled them to improve the care quality experience and achieve positive outcomes and good quality of life for people. Feedback we received from people confirmed this.

The management team had a focus on continuous learning and improvement across the organisation and local system.

The management team demonstrated how processes in place at the service had led to continuous learning and improvement to enhance peoples’ outcomes. The management team had carried out reflective supervision and learning with individual staff where incidents or near misses had occurred.

The directors had significantly improved the living environment for people to reduce the risk from fire, infection risk and environmental hazards. The management team had a robust service improvement plan in place to improve people’s care provision at Mount Vernon Terrace. This plan had made significant progress to ensure the service provided was safe and effective for people.

A member of staff told us how they were being supported to further their learning. They said, “I am currently doing my level 4 NVQ, the management team have been really supportive of this. They are also supporting me to do my level 5 NVQ in September, which I really appreciate.”