Mount Ephraim House

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.

This is the first assessment for this newly registered service. This key question has been rated 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 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 always 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.

The provider had not ensured regular staff supervision and team meetings were held to embed a culture based on a shared vision within the staff and management team. Although senior managers were present in the service at the time of inspection, people and relatives told us this was a recent involvement, and they had not seen them prior to this. A person said “Senior managers have been in a lot recently. Not before, not at all.” A relative commented, “Head office have been here in droves, but I’m not sure what they have been doing.”

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.

People and relatives told us they had raised areas for improvement with leaders, however, they felt they were not listened to, so improvements that were important to them were not made. We were told these frustrations had been ongoing for some months. These included the lack of equal or independent access to the garden area and the quality of food served as referred to in other areas of this report. The now vacant registered manager post highlighted their concerns further and although some people and relatives had offered to be involved in the recruitment to this position; to support the voice of people living in the service, this was not taken up by the provider.

A person told us, “There is a lack of consistency, a lack of information, and it is going downhill.”
The comments we received from relatives included, “We did not see anyone from head office until a few weeks ago. I had high hopes for them but they just talk the talk”, “The staff are very nice but there are many agency so no consistency, but management and leadership are very poor”, “I think they are waiting for a permanent manager, so things have been a bit unsettled”, “There are lots of areas for improvement, but it could be worse”, “My slight concern is that because communication is a bit chaotic, I do wonder if that reflects on how the home is run. My other concern is that from chatting to staff, they seem to be unaware of what is going on because of the recent managerial upheavals” and “They need good leadership and a strong management team in there, and also somebody in authority at the weekend when I think things tend to slip.”
 

People did not always feel they could speak up and that their voice would be heard.
Concerns were raised with CQC by relatives about their loved one’s care prior to the inspection and by people and relatives during the inspection period about not feeling listened to. They told us they had raised concerns, but no action was taken to improve the quality of care and support. Staff had not advocated for people to add their voice to improve people’s experience at the service.
The numbers of agency staff covering shifts meant there was an increased risk concerns may not be raised with the provider.

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.
There was a clear policy of Equality, Diversity and Inclusion and this was evident from the staff base.
 

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 a clear oversight of quality and risk in the service which meant the potential of people being at risk of harm was increased. The provider had not ensured their systems to monitor and improve the safety and quality of care provision were used effectively.
Monitoring and auditing processes were ineffective in picking up issues within the service, and the provider’s quality assurance procedures had not been followed regularly by the service. Provider audits had not been undertaken in line with the provider’s own policy, to ensure an oversight of risk.
Service audits had not been completed regularly and where issues had been identified, action had not been taken to ensure timely improvement. For example, a medicines audit completed on 9 July 2025 identified guidance to ensure safe administration of ‘as and when necessary’ medicines such as painkillers were not in place. We found this was still the case when we visited in August 2025.
The provider completed only 1 ‘quality and operations compliance visit’ in 2025, which was the tool used by the provider to check the quality and safety in the service. This demonstrated a lack of effective oversight and leadership at the service.
 

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.
Although the service worked in partnership with safeguarding and other healthcare professionals such as GP’s and occupational therapists, staff and leaders did not always engage and collaborate with a range of communities and partners to share learning to support continuous improvements to the service.
 

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.

A learning culture was not embraced within the service to ensure safety was a priority. Although accidents and incidents were reported by staff, ineffective monitoring systems meant opportunities were missed to learn lessons and prevent further occurrences. The provider’s response to learning lessons from recurring incidents and lack of action taken to improve outcomes for people was poor creating the potential of ongoing risk to people in their care. Staff meetings were not held to share lessons learnt and what constituted good practice across the staff team.
The provider missed the opportunity to learn and improve from people’s feedback, complaints and from quality assurances processes, leading to a lack of improvement in the service.