Mount Ephraim House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

This is the first assessment for this newly registered service. This key question has been rated
requires improvement. This meant people’s needs were not always met.
 

This service scored 54 (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 always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The provider’s systems were not effective in making sure people, and their relatives where appropriate, were involved in developing their care plans. Care plans did not always provide the level of detail to ensure a person-centred approach to people’s care and support.
Some people’s care plans provided personal detail about people’s lives past and present and what was important to them, providing clear evidence they had been involved in creating their care plan. Personal information had been gathered from the person and was written from their perspective. For example, a person's care plan recorded quotes from them about how they were at times forgetful and may need some reassurance and who they wanted to support them with big decisions.
However, the quality of people’s care plans was inconsistent, and some care plans did not provide any of this detail. There was a risk some people would not receive care in the way they wanted and needed, particularly due to the heavy reliance on temporary agency staff.
Some relatives told us they had been involved in people’s care planning, however most relatives said they had not been asked to be involved. This created a risk that staff would not be provided with the information about people and what was, and had been, important to them, particularly if a person was living with dementia and were not able to share this information themselves.
The comments we received included, “I have been (involved in the care plan). It seems to be regularly reviewed”, “No, I have not (been involved in the care plan). I believe there is one, but I have not got involved with that at all” and “There is a review booked for September. We have only been told about that recently since CQC have been in.”
 

The provider understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Systems were in place to enable people to receive appropriate and skilled joined up care from external community services. Staff identified concerns with people’s health needs so they could receive the care they needed before further issues arose.
 

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Some people and relatives shared they did not feel they were always provided with the information they needed or requested.

Relatives had different experiences in relation to how and when they received information. The feedback was mixed, comments included, “Communication with relatives is very poor”, “We tend to tell them (staff) if we think they (relative) have got worse. We have never had a care plan review with them” and “No, they don't check with us about anything. We always have to go to them.”
Other relatives commented, “They are always open, and I think that if I ever need them to talk about anything, there are always staff about and available to listen” and “They keep me regularly updated if I have not been in for a while. If there is a problem, they will ring me.”
 

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

Although complaints had been raised and the provider had a complaints tracker, people and relatives told us about concerns they had raised, and these were not recorded on the tracker. People told us they had raised concerns more than once about having safer access to the garden to enable independent walks. Despite their repeated requests, they had not had satisfactory feedback. The complaints tracker did not reference these concerns.

Meetings were held with people living in the service and with relatives, we received negative feedback in relation to the outcomes of these meetings. When issues were raised, we were told there was little evidence of action being taken. A person told us, “Meetings are not regular and there are not a lot of results. We are often told things raised are going to happen, but they don’t”. We had very similar feedback from relatives in relation to the relatives' meetings held, with relatives feeling frustrated. A relative told us about a meeting in March 2025 where none of the actions discussed had happened.

People and relatives told us they had complained more than once about the food and the dining experience, such as the quality of the food served, tables not being set properly, tables and chairs not being clean and the availability of condiments. A senior manager had recorded a complaint about food on 3 August 2025 when they were visiting the service and witnessed an unsatisfactory meal. However, complaints had been made prior to this that had not been logged and timely action had not been taken to make improvements.

People and relatives had asked for inclusion in the recruitment of a new manager which was taking place at the time of the inspection. We received feedback that this had not happened.

The feedback we received included, “We have raised concerns - many minor that then became bigger. Occasionally a quick fix was done, but the issues started again as the source of the problem was not dealt with” and “I know my father has complained over a few things about communication which has on occasions been very patchy. I can vouch for the fact that communication is not always very clear. For example, I would definitely not know who to approach if I did have a complaint or concern.”

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.
Some people felt they were not treated equally in being able to access all parts of the service they wished to, for example the garden. Some people had raised more than once that they would like to be able to access the garden on their own, when they wanted to, but felt unsafe with walking aids. People did not feel listened to as they had not had constructive feedback or a plan. A person said, “I feel it is too late now to be able to safely take advantage of accessing the garden during the summer months.” A relative told us of their concerns that their loved one had not been able to access the garden or the balcony to get some fresh air. They had received promises but without success. This meant some people were restricted in being able to access facilities that may support their well-being.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

There was mixed feedback in relation to activities provided at the service. Relatives told us they did not think there was equal access to meaningful daytime activity for their loved ones, particularly those cared for in bed and for those who wanted more individual opportunities, such as previous interests and hobbies. A relative said, “I think that is our main issue is that there are not enough activities geared around male residents. As a result, I don't think there is enough mental stimulation for him. The staff do say that they ask him whether he wants to join in, but it is the type of activities that he is not interested in. (Relative) Is more of a hands-on person who likes doing things with his hands.”

Other relatives thought their loved one's needs were catered for with the activities offered, “One of the activities is a Communion within the Home on a Thursday morning, which she does choose to go to. On Sunday they have a church service on the TV in the lounge, and she watches the same service in her own bedroom.” and “There is usually quite a lot going on. They have sing along sessions, group activities and exercise classes like throwing a soft ball around etc.”
 

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People had advanced care plans in place, describing their wishes around their care at the end of their life. For example, if they wished to be transferred to hospital or supported to remain at Mount Ephraim House and receive treatment, if they had a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order, their important religious requirements and if they had specific funeral preparations.