Mentaur Community Support Limited

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 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 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 in governance of the service to ensure it was robust and effective in day-to-day quality assurance. Audit processes needed strengthening to help the management team identify areas of concerns and the actions required. We looked at a range of audits, and these did not identify all our findings during this assessment. An example of this was the medicines audits. They had not identified people’s topical creams and sprays did not have an opening date, or that risk assessments were not in place for flammable creams. Staff had completed some training, however further work was needed to ensure all staff were up to date and had received appropriate training for the tasks they supported.

Improvements were required in relation to the culture of the workforce, and communication with staff required improvement. Some staff described how staffing levels and communication from

the management team impacted on their ability to do their job.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. However: We received mixed feedback from staff with some saying they felt supported whilst others not. There was a registered manager in post who told us they felt supported. Systems were in place for gathering feedback such as meetings and surveys, however no surveys for residents or relatives had been completed in 2025.

Audits and spot checks were being carried out, and some issues we identified- such as care notes lacking sufficient detail- had been identified. However, these improvements were not yet fully embedded. The management team acknowledged this and were committed to strengthening audit processes and increasing spot checks.

The registered manager demonstrated good knowledge of people and was receptive to feedback during this assessment. However, leadership assurance processes require further development to ensure consistent support for staff and fully embedded quality improvements.

People did not always feel they could speak up and that their voice would be heard.

Team meetings did not show clear evidence that staff were encouraged to speak openly. Whilst meetings were held regularly, these would benefit from promoting wider participation and more open discussion.

The staff handbook referenced whistleblowing but did not provide sufficient detail on how or where to raise concerns beyond reporting to a director or an external organization. This lack of

clarity may limit staff confidence in escalating issues.

Feedback gathered from staff in person was mainly positive. However, email responses contained fewer positive comments, indicating some staff may feel less confident to speak openly. Not all staff were familiar with the term “freedom to speak up."

When staff do not feel able to raise concerns, risks may go unreported or unaddressed, reducing opportunities to prevent harm. Policies on whistleblowing and freedom to speak up were in place.

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.

Staff had access to 24-hour support line and received regular supervision. We saw examples of reasonable workplace adjustments being implemented, although some staff told us their requests had not been supported.

The provider promoted equality, diversity and inclusion through policies, procedures and training. Staff completed equality and diversity training, and we found the workforce to be diverse. Staff surveys had been conducted to gather views and monitor staff experience.

Overall, the service demonstrated a commitment to fair and inclusive practice, with some areas requiring more consistent application to fully embed an equitable working environment.

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.

Governance systems were not effective. Audits did not identify all key concerns, including lack of goals and aspirations in care plans, and gaps in medicines records. Some audits lacked clarity about what was reviewed or who was consulted, reducing their reliability. For example, the January 2025 communication audit did not specify which staff were spoken to.

Where audits did highlight issues, there was limited evidence that actions had been taken or that concerns had been resolve. For example, the monitoring visits from November 2025 identified the fire risk assessment from July 2025 was not in place, this was still the case during this assessment, resulting in some of the actions required not being completed. The providers action plans did not reflect all the issues we identified, and oversight processes were not robust enough to detect shortfalls such as gaps in medicines management. These weaknesses increased risks to people using the service.

Although some improvements were made during this assessment- such as verifying LPOA documents and updating medicines temperature recording guidance- these were not fully embedded, and sustained oversight was lacking. The management team acknowledged these issues and plans to strengthen governance.

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 saw evidence of effective partnership working with external health and social care professionals, including GPs, social services, nurse practitioners and an NHS physiotherapist. A visiting professionaltold us staff knew people well and had no concerns, though encouraged staff to encourage and support people to go out more.

People's views were gathered through surveys and were generally positive. As part of our assessment, we sought feedback from external partners, which was also positive. Visiting professionals we met during the visit described staff as approachable and knowledgeable about the people they support. One professional told us, "The staff are approachable and seem to know the people well, we see good interactions."

Overall, the service demonstrated strong and constructive relationships with partners and the wider community, contributing to positive outcomes for people

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service had some systems in place for learning and improvement, including regular staff meetings, though these did not show that staff were consistently encouraged to share new ideas. Some staff told us they felt confident to speak up but others not.

Quality assurance monitoring was taking place and included actions to be completed. However, follow-up was inconsistent. For example, a monitoring visit 6 November 2025 identified that a fire risk assessment document had not been received and required the registered manager to follow this up. At the time of this assessment, this was still not in place.

Overall, systems and processes to assess quality and drive improvements were not fully effective. Action plans were in place but did not include all the concerns we found and were not consistently implemented. The service had moved to an electronic monitoring system in 2025, however this was not yet fully embedded.

Despite these gaps, the management team responded openly and proactively to the feedback we provided during the assessment and took steps to begin addressing the issues identified. Strengthening governance systems, ensuring documentation is complete, and embedding consistent practice will support improved outcomes for people.