Montagu Hall Care Home

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 to confirm 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 outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (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 very clear 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 in their understanding and implementation of the provider’s vision for the care home which was based on meeting people’s needs and actively involving them in their care and the running of care home. There was a positive and welcoming atmosphere throughout the care home and members of staff were keen to show and share how care was provided and how people’s outcomes were supported. The registered manager told us, “I am very family oriented, and I want us all to feel like a happy community with a family feel where people are involved in their home and their relatives are involved in the care of their loved ones.”

The provider had exceptionally 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 always did so with integrity, openness and honesty. There was a strong, dedicated management team who were focused on delivering the best possible care and support for people to achieve their outcomes. The management team were extremely motivated and enthusiastic and were constantly looking for areas where they could improve and develop the service. People told us the service was well-led. One person told us, “The [registered] manager’s door is always open and I can go and talk to them.” Another person told us, “Yes, the service is well-led.” A member of staff told us, "I know if I have a problem, I can go speak with the registered manager at any time and also the deputy manager. I feel comfortable knowing I can do so and if a member of the management team is not available, then I can speak with the unit lead or senior. If I really needed to speak with the general manager and they were not in, then I can always send them an email.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was regular engagement with people and their relatives, and they felt listened to. Member of staff were confident the management team would resolve any concerns immediately. A member of staff told us, "I have always felt able to discuss new ideas and have felt my views are respected by the registered manager. The management team will listen to ideas and discuss options."

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. The provider had an equal opportunities policy not to discriminate against its employees. The principle of non-discrimination and equal opportunities applied equally to the treatment of visitors, people and members of staff. Arrangements were in place for members staff which facilitated flexible working and time off to attend appointments and special occasions.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider had a detailed and robust governance framework in place. Audits, reviews and service monitoring tools were completed monthly and key performance indicators were reviewed and analysed by the registered manager and the management team. The outcomes from the monitoring and reviews supported the management team to manage quality and inform continuous service improvement and development. We saw evidence people were involved in aspects of governance including front of house audits, regular meetings and feedback about quality.

The provider clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. The service had made links with local community groups and organisations to support inter-generational engagement opportunities. Through discussions at residents’ meetings, engagement with local early years setting was an area where people wanted to develop links and visiting opportunities. The management team worked with a local nursery and invited the young children into the care home for a visit. Some people who lived in the care home had previously worked in early years education and this engagement opportunity enabled them to reconnect with their passion for teaching young children. There were positive outcomes for everyone from the initial visit and weekly visits were put in place. This programme has supported people to socialise with each other and allowed them to spend time with young children from the local community. The inter-generational engagement programme supported positive mental wellbeing outcomes, promoted movement and improved cognitive and social skills for people who live in the care home and the young children who visit from the local nursery. The provider had a positive approach to partnership working and worked collaboratively with people, relatives and external partners. The provider had engaged with community group services so people could thrive, have new experiences and live the life they chose.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. We saw learning from incidents was shared with the staff team to ensure the quality of care was improved. Where serious injuries were sustained, we saw the management team had completed a ‘root cause analysis’ to look identify learning to support continuous service improvement. If improvements were needed to practice, or changes to care plans or risk assessment, these had been completed promptly to reduce the risk of reoccurrence. Reflective practice was used as a tool to inform and consistently improve the quality of care and support. The management team and members of staff ensured people, and their families, were involved in building a culture which focused on enabling people to enjoy a full and active life. The registered manager met with their peers across the provider’s network of services where lesson learned, performance and service updates were shared and discussed.