Mountfield

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 requires improvement. At this assessment, the rating has remained requires improvement. This meant the service’s quality monitoring systems had not been fully effective at identifying and rectifying shortfalls. We found the provider to be in breach of the legal regulation relating to governance.

This service scored 61 (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 clear shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding the challenges and the needs of people. However, evidence showed effective systems were not in place to ensure staff consistently worked to this culture and vision. For example, feedback from people told us that whilst staff were consistently kind and caring, the level of care received was dependent on which staff member supported them. Whilst we saw the management team worked hard to rectify this through supervisions with staff, people told us they wanted to see more of the management team overseeing the care deliver to help rectify this shortfall.

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.

The leaders of the service demonstrated to us their commitment to improving the service and a considered and responsive approach to the shortfalls found at this inspection. We saw them work hard to make changes in response to our feedback and collaborated with us with transparency and honesty. Staff also spoke positively about the management team with 1 telling us, “The leadership team is approachable and visible. They are open to feedback and take action when concerns are raised. There is a clear sense of direction, and staff are encouraged to share ideas for improvement.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard; the people we spoke with told us this. One relative said, “I have mostly contacted the deputy manager who seems on the ball with things, and I would talk to them about any issues.” Staff agreed. One said, “The management team are very nice and support the staff and residents. I feel comfortable talking to them.”

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. We saw this during our inspection and people told us this. One staff member told us how accepted they felt as part of a diverse workforce and that their cultural needs were supported and met.

The provider had clear responsibilities, roles, and systems of accountability in place. However, their governance systems had not been wholly effective at identifying and rectifying the shortfalls found at this inspection.

For example, whilst some of the provider’s quality monitoring audits had identified the shortfalls found at this inspection and were in the process of being actioned, some shortfalls had not. A provider audit had also not been completed in the time specified by their policy. Whilst care plan audits had informally taken place, formal audits had only started in March 2025 and this had negatively impacted on the consistent quality of people’s care plans.

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 health and social care professionals who provided us with feedback told us this and records confirmed it. However, people had little opportunity to engage in their local communities and few events occurred outside of the home. People and their relatives told us they would like this to happen, particularly as the activities that occurred within the home did not always meet people’s interests. One person who used the service said, “It would be lovely if they could arrange a get together for the ladies and 1 for the men. We don’t have any involvement in the local community.”

Whilst the provider focused on continuous learning, innovation and improvement across the organisation and local system, this had not always been wholly effective and people’s outcomes were not consistently equal as a result. Reflection was used to improve the service and staff told us they were encouraged to problem-solve. However, although feedback was sought on the service from the people who used it and their relatives, this was irregular. Feedback from other stakeholders, such as health and social care professionals, was not formally sought.