High Mount

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. The service under a previous provider was rated Inadequate for this key question. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 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 management team were clear they wanted to improve the service and outcomes for people both in their experiences and the environment. The registered manager and home manager worked well together and shared with us action plans and improvements they wished to make to the service. Staff felt empowered and told us improvements had happened, and the atmosphere and environment had really improved. One staff member told us, “The new provider and manager has been a positive move. Things get done now and I feel supported”.

The provider 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. Since the last inspection the previous registered manager had left and a provider change had happened. There was a registered manger in place. The care home manager was applying to take the registration of the home. The provider had notified CQC of these changes. The management team knew people well and were passionate about making sure people received good quality care. They were supported by the provider. The management team were present at the service regularly and undertook checks and audits. The care home manager also provided ‘hands on’ support and completed care shifts as needed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were encouraged to share their ideas and be part of any changes or improvements to the service. Staff were aware of procedures the provider had to raise any concerns and who they could speak to outside of the provider. One staff member told us, “I would raise concerns to the safeguarding team or CQC, however, I have not needed to as management report straight away”. Staff were aware of whistleblowing and where they could access information on this service.

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. Actions following our last inspection had taken place. The new provider had embedded processes to improve the previous concerns around culture within the home. Staff received gifts for their commitment and support from the provider, who ensured they were recognised for their achievements.

The provider had responsibilities, roles, systems of accountability and mostly 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. During this assessment we identified 2 incidents reportable to safeguarding which had not been reported. We raised this with the registered manager and new care home manager. The timings of these incidents were when the previous registered manager left, and the new home care manager came into position. This highlighted where these had been missed and not reported. No impact to people was present from these incidents not being reported and the provider took appropriate steps to ensure the person was safe. During this assessment, the new care home manager raised the incidents to the local safeguarding team. Since our last inspection the provider had been auditing and checking the service. There were monthly audits completed by the area manager and regular audits by the provider's quality and compliance team, the manager and deputy. These had provided a robust structure to highlight and manage any shortfalls in the service. For example, medication audits were completed, these were checked by the home manager and deputy manager. The registered manager would then complete a spot check audit to ensure the medication audit had been completed correctly. The home received internal reviews from a quality auditor, this is where the auditor would review all records, including care plans, risk assessments, audits and health and safety checks. We received mixed feedback from relatives around how things were communicated to them. For example, when the provider changed, this was not clearly communicated. One relative told us, “We are aware there has been a change in the provider and that the management has changed, during these times communication could have been better to help us understand why these changes were happening”.

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. The manager told us they were working closely with the community and trying to expand opportunities for people. All staff worked with visiting health and social care professionals. Staff explained how they welcomed visitors. We observed some people were supported to get out into the community to access shops and fresh air and some activities. Due to the ageing culture of people, activities and structure was difficult to embed into the home. We received feedback from commissioning teams that identified the changes that had taken place had positive outcomes for people living in the home. During our visit we saw people going out to complete clothes shopping andanother person going to the local community centre. People were playing garden games, music was on and staff were encouraging and engaging people to join in.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The new provider and manager worked to embed improvements ensuring all staff are skilled and trained. The home manager also completed observations around the support staff provided to people with eating and drinking needs. The care home manager and registered manager had a clear action plan that identified the stages they were at with the improvements they wished to make. For example, improvements to the bungalow’s decoration had clear actions to be completed each month. Where accidents or incidents had happened, these were reviewed by the manager and learning for the future was taken and communicated to staff. The service also shared any learning further into other services the provider manages. The provider held regular management meetings and this included CQC updates and organisational updates.