Mountfield House Care Home

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• 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

Governance and oversight systems had improved since the last inspection, however more improvements were needed to some oversight systems. There was no oversight of DoLS applications to ensure the outcome was documented in people's care records and appropriate notifications were completed. However the provider had made improvements to other areas of the governance and oversight arrangements in the service. Systems were in place to check on the quality of the service people received, identify areas for improvement and ensure these were completed. Audits were in place to monitor care plans, check on the environment and equipment in the service which were ensuring actions were taken to make improvements.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Plans were in place to support people in an emergency. Staff told us about people's individual emergency evacuation plans which were in place to support people in an emergency. Audits were in place to monitor the service delivered. The registered manager told us they had a series of audits in place to ensure people received the care and support they needed. Audits included care plan audits, checks on the building safety and questionnaires to find out about people's experiences of the service.

Systems had improved since the last inspection to offer oversight. For example, there were checks in place on care plans, medicines administration and building maintenance. However more improvements were needed. There was no system in place to offer oversight of Deprivation of Liberty Safeguards. There was no system in place to track the outcome of DoLS applications. This meant there were delays in understanding when a DoLS had been approved and information was not added to peoples care records in a timely way. Notifications were not consistently submitted when required. When DoLS applications had been approved they had not been identified and therefore notifications had not been submitted, these were submitted following discussion with the registered manager after the assessment site visit.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.