Mount Joyce Care Ltd Also known as Mount Joyce Care Ltd - Kettering

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

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.

This is the first assessment for this service. This key question has been rated requires improvement.

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 good governance.

This service scored 46 (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. They did not always understand the challenges and the needs of people and their communities.

Improvements were required to governance of the service to ensure it was robust and effective in managing day-to-day quality assurance. Audit processes needed strengthening to help the management team identify required actions.

Regular meetings took place where staff had the opportunity to raise any concerns, and staff told us they felt supported.

Whilst staff undertook some training, more was required to ensure they had received the training for the tasks they were supporting with. Regular communication amongst staff supported shared learning and experience.

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

Staff told us management provided them with the support they needed to do their job effectively.

People did not always have reviews of their care within the timescale. However, the management team regularly completed care calls and told us they are continuously reviewing and that this would be recorded in the future. People told us, “The managers are very friendly and flexible. When I have needed extra care for my relative, they have come in and helped”

Despite positive feedback from staff and people who used the service, we found that the management team did not demonstrate clear insight into issues affecting the quality of the service. The management team completed some audits and checks within the service. These had not identified the issues we had identified. There was an improvement plan in place, but this failed to identify any of the shortfalls we identified or any previous shortfalls from service audits.

The registered manager was currently completing their level 5 NVQ in Health and Social Care.

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

Staff told us they were confident to raise any concerns, though not all were confident they would receive feedback. Team meetings were held, but the minutes were not shared with staff. We discussed this with the management team who told us they would share the minutes going forward.

The service had policies in place such as freedom to speak up/whistleblowing. However, the policy stated that Mount Joyce Care Ltd will have a freedom to speak up Guardian. This was not implemented until the time of the assessment.

The provider valued 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.

Staff told us that flexible working arrangements were not discussed during the interview process.

The staff handbook did not contain information about support for people working on a sponsorship visa. We discussed this with the management team who told us they would add this. The service had no processes in place to promote workforce well-being. This was discussed with the management team who advised they will be implementing a staff reward scheme.

The service had policies on workforce equality, diversity and inclusion, but improvements were needed to ensure these were actively promoted and embedded into practice.

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.

The provider did not ensure there was suitable governance arrangements in place that identified shortfalls. For example, where care plans needed more information about the person such as what support they needed with catheter care, skin care, equipment and any associated risks. We also identified shortfalls in ensuring incidents and accidents were recorded, reviewed and actions taken. Staff also needed training in catheter care and end of life support. Although people and their relatives told us they did feel able to raise concerns, the service did not have log for complaints, accidents or incidents this indicated a lack of opportunity to identify themes and trends and lessons learnt. Additionally, they did not follow their own complaints policy.

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 failed to have systems in place to check the quality of the service. There were some audits of, medicines, and care records. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, the medicines audits had not identified the concerns we found in relation to administration timings or recordings. Care record audits failed to identify that daily notes did not always contain enough information or appropriate language. Audits had also not detected that care plans and risk assessments were lacking detail and were not always up to date and accurate.

However, people’s experience of the service was positive, and we found no evidence that the concerns we had identified had impacted on the quality of people’s care. However, there was poor oversight and governance of the service which placed people at increased risk of harm.

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.

We received positive feedback from professionals, who told us, "The provider worked at pace to rectify to shortfalls and were keen to work with us."

People's feedback was sought through surveys, which were generally positive, though not all were dated, making it difficult to track when completed.

We saw evidence of partnership working with GPs, social services and nurse practitioners.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and research.

The management team did not consistently contribute to safe, effective practice or monitor this through effective governance. We spoke with the Registered Manager who was open and receptive to the feedback throughout this assessment. The Registered Manager acknowledged that care planning was lacking, and audits had failed to identify these risks.

The provider failed to monitor service performance effectively. Records indicated that the service did not always focus on continuous learning, innovation and improvement. The lack of accident, incident and complaints records meant lessons learnt, trends, and preventative actions could not be identified.