Mont Calm Residential 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

We identified 1 breach of the legal regulation. Processes in place as well as the ethos, values, and behaviours of leaders and care staff did not always ensure people using services were supported in an inclusive, empowering way and had good experiences of their care. Quality governance systems were not effective in identifying shortfalls in care. Staff did not always feel confident in being able to speak up if necessary and did not always feel supported in their roles. During our assessment of this key question, we found concerns around the lack of robust oversight and lack of assurance processes.

This service scored 29 (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’s quality frameworks did not always recognise best practice and were not effective in identifying shortfalls in the care people received or gaps in people’s care records. The registered manager told us they had created the bath schedule to ensure people were bathed at least once a week. This was not encouraging a culture of person-centred care in the home. Leaders of the service did not demonstrate the required experience or capability to deliver person-centred care or to ensure risks were well managed.

There was a lack of evidence that staff were reminded of the values and shared direction. There was a lack of evidence of any robust auditing or oversight of people’s care to ensure all people had the same opportunities. Care records showed people received institutionalised care that was more to benefit the staff daily routine as opposed to people being treated as individuals. The provider failed to recognise they had developed a culture that did not robustly promote or uphold people’s rights

Staff told us they felt supported. Comments included, “The manager is friendly and honest” and “They support me all the time.” Whilst staff did not raise concerns with us directly, other evidence showed senior leaders at all levels did not understand the context in which care needed to be delivered in a compassionate and inclusive way. The leaders did not have the necessary skills and knowledge to ensure staff providing care to people living with dementia were doing so in a safe and effective way.

The registered manager told us they did not have any formal schemes in place to recognise and reward staff for their contributions. There were very infrequent staff meetings, and those we were sent evidence of, related to concerns that had been raised by the local authority. This meant staff did not have opportunities to feedback collectively about any concerns they had or to be involved in the running of the home.

There was a mixed response from staff on whether they would feel confident speaking up. Most staff told us they were not aware of the whistleblowing policy. Staff also a concern raised that staff were often speaking in a foreign language and that this had not been addressed by the leadership team and felt they could not raise it.

The provider had a whistleblowing policy in place but did not ensure staff were able to recognise concerns and could implement this policy in their day-to-day work. For example, we observed a senior member of staff incorrectly using moving and handling techniques putting the person at risk of avoidable harm. Other staff who witnessed the event did not recognise or report this as a concern and their account of what we observed was inaccurate. Although staff were asked to complete satisfaction surveys, there was not sufficient systems in place for staff to report back anonymously.

There were staff who felt the leadership team were inclusive and valued diversity. However, there were other staff who felt there was a lack of equality in how they were treated. The registered manager told us in the PIR (Provider Information Return sent to the CQC), “Staff members have been confident to come forward (about concerns they have).” However, we found this was not always happening in practice.

There was an equality and diversity policy in place and staff had received training around this. However more work needed to be undertaken to create a working environment and culture where every member of staff could experience a sense of belonging and empowered to achieve their full potential.

The registered manager and a senior member of staff told us about the audits they undertook. However, the provider told us, “The robust oversight, we need to record data better. I intend to monitor more. I do visit the home at different times. I am fully aware if it’s not documented, it’s almost like it hasn’t happened. I need to be better at recording my visits.”

The provider’s governance systems were inadequate and failed to recognise a range of shortfalls in people’s care and the service. The provider and registered manager failed to identify through audits that decision specific mental capacity assessments had not been undertaken when required. There was no evidence of how people’s best interests had been considered and how decisions were made to ensure least restrictive support. The provider was unable to provide evidence of an effective system to assess, monitor and improve the quality and safety of the services provided and to ensure they had met the regulatory requirements. There were no audits of care notes, care plans, or direct observations of staff interactions with people, so there was no assurance on how the provider monitored the quality and safety of people’s care.

Relatives told us there was not always a joined-up approach between them, partners and the home to ensure the best possible delivery of care.

The registered manager told us on their PIR (Provider Information Return sent to CQC), “We also work in partnership with pet therapy team, who comes in the home to provide activities to stimulate service users monthly. We also work in partnership with British Legion, who brings the Poppy Donation tins on a yearly basis and residents always looks forward to having a poppy. We have also been working with Skills for care (the strategic workforce development and planning body for adult social care) that has been providing manager's networking opportunities.” Whilst we saw this was the case on a service level, there still remained a lack of joined up approach to ensure individual people’s care was person-centred.

Partners told us they generally had good working relationships with the registered manager and staff at the home. However, there was also concerns that when they made recommendations for improvements at the home, these were not always actioned in good time.

The provider had systems and processes in place to engage with external partners. However, this was not coordinated in a way that would benefit people and improve their experiences of care.

Whilst the registered manager told us they always looked at ways of improving care and people’s experiences, we found this was not happening. They were not always able to demonstrate any evidence to support this.

We found there was not sufficient learning around care being delivered to achieve better outcomes for people. For example, where people had been regularly given ‘as and when’ anti-psychotic medicine but there was a lack of evidence of action taken to look at whether the care being provided could be changed to reduce the person’s anxiety.