Moundsley House

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 looked at 2 quality statements under the Well-Led key question: Capable, compassionate and inclusive leaders and Governance, management and sustainability. We found concerns in relation to risk management. Safety concerns identified at this assessment (detailed in the safe section of this report) had either not been identified by the provider or had been identified but not mitigated to reduce the risk of harm or injury to people. These concerns resulted in a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The concerns identified were discussed with the provider at the time of our assessment and steps were taken to start addressing these issues. The provider was in the process of implementing new governance checks, processes and policies to improve oversight, quality and safety. Time was needed for these to be embedded and sustained. People and relatives told us they felt the service was well managed and communication was good.

This service scored 71 (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.

Staff told us leaders were visible and the registered manager was approachable and supportive. One staff member told us, “I feel supported, and staff are treated fairly”. Staff were positive about working at Moundsley House, one staff member told us, “We do a lot of teamwork, we are here to give the quality of care people need and deserve and respect their wishes”.

The service had a registered manager in post who was suitably qualified and experienced, they were supported by the head of operations and clinical lead. Regular managers meetings were held with the head of operations and the registered managers from the sister homes to share learning and best practice. Systems were in place to gather feedback from people, relatives and staff however, no analysis had been undertaken to look at areas of improvement. The head of operations had recently sent out surveys to relatives and advocates and told us they would be reviewing these to look for any themes.

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.

The registered manager told us they held weekly meetings with heads of departments and daily handovers between shifts to share information, concerns or actions required. Staff we spoke with confirmed meetings took place and were informative. Staff were confident of the processes they needed to follow, for example, if a person fell or in the event of the fire alarm sounding. They worked alongside health care professionals such as the speech and language therapist and the frailty team to ensure people’s health care needs were met.

Whilst there were a range of audits and checks in place to assess the quality and safety of the service, we found that these were not always effective and had not identified some of the concerns we found in relation to safe environments, risk assessment and medicines management. We found that accidents and incidents were reported and recorded but no analysis had been undertaken to identify patterns and trends to help identify measures to reduce further occurrences. Risk assessments were not always in place to mitigate the potential risk of harm or injury to people. Staff meetings were held, minutes from a meeting held in September 2023 recorded ‘all residents need teeth and denture care’ and ‘bed rails require bumpers’. We found these were still an issue during our assessment. This meant lessons were not always learnt. Following our assessment the registered manager confirmed that risk assessments had been put in place for the areas of concern we identified and they had started undertaken analysis of accidents and incidents. New quality assurance processes and systems were being implemented at the time of our assessment to improve oversight of the service. The head of operations had an action plan in place with findings from internal and external audits to monitor improvements made. The action plan was reviewed with the registered manager weekly.

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.