Mount Vernon Terrace

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

There was a lack of clear and effective governance, management and accountability arrangements at Mount Vernon Terrace. Although staff understood their role and responsibilities, the management team were not fully accountable for the actions, behaviours and performance of staff. The systems to manage current and future performance and risks to the quality of the service lacked a robust approach to managing risk that allowed a therapeutic and innovative approach within the service. Data or notifications were not consistently submitted to external organisations as required. There was a lack of robust arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was not being used effectively to monitor and improve the quality of care. Leaders had failed to implement recognised standards, best practices or equivalents to improve experiences and outcomes for the people living at the service. The service was in breach of legal regulation as systems and processes failed to assess, monitor and improve the quality and safety of the service provided.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a service improvement plan in place to track developments and ensure the required measures were taken to maintain and improve the service to safe standard. The management team all had responsibility for ensuring these actions were completed. They acknowledged there were areas which required significant investment and embedding to ensure service improvement. One member of staff gave positive feedback about the management of the service, and their support. They told us, “For me, it is a special workplace. I enjoy it, we are like family, but we have boundaries. Staff work well, there are no dramas, we work as a team.”

The management team had failed to implement improved systems to deliver a positive experience, and good quality of life for people. Previous shortfalls identified in care quality, found at our previous inspection had not been addressed; For example, there were no audits in place to show when the Mental Capacity assessments were completed, the outcomes of such assessments, or when they should be reviewed. The absence of a mental capacity assessment for appropriate decisions demonstrated a lack of understanding around the Mental Capacity Act which posed a risk to services users of not having lawful decisions made about their care.

The directors had given their commitment to investing and improving the service, acknowledging previous shortfalls found. We will review their implementation of the required improvements at our next assessment visit. The management team had a positive working relationship with the staff team. Our observations of their interactions with people, professionals and staff during the site visit indicated they were committed to making the necessary improvements. A staff member told us, “The managers are accommodating. I do feel supported, guided. I can always contact the manager, even when they are on leave.” Another staff member told us, “Some people wouldn't survive working this environment, but we enjoy it. We work well I feel.” One person we spoke with gave positive feedback regarding the support the service had given to them. They said, “I would like to take this opportunity to thank the team at Mount Vernon Terrace for providing on-going support with my on-going recovery.”

The service had plans in place to further improve the living environment for people. The director had a service improvement plan in place with a tracker for progress. However, we saw the dates for completion of some of these actions were significantly future dated. This left people exposed to the risk of harm in the immediacy. Auditing of progress was being completed by the director. We requested an action plan from the management team, with updated information on how they expected to achieve levels of safe care at Mount Vernon Terrace.

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 management team had a service improvement plan, business continuity plan and emergency plans in place. However, we found evidence of progress towards the stated outcomes was minimal and the plans required embedding to improve the quality of care. The director explained how they were committed to investment in the service and staff team to ensure future service development.

There were irregular audits taking place of people’s care plans and daily records which meant the management team had no effective oversight. Therefore, people were placed at risk of having unmet needs. Actions taken by the management team after our assessment visit to improve the processes in place for reviewing this documentation provided assurance this had been addressed for people with specific needs. The management team had not ensured the governance systems and processes in place to manage risk were effective. There was accident, incident and falls analysis in place which had not been utilised to identify themes and trends. Which would in turn inform them of how to improve support and safety for people. The management team showed a lack of evidence of lessons learned and improvements being implemented as a result of incidents that had occurred. The management team had not always ensured they were being open and transparent, by reporting all notifiable incidents to the Local Authority and the CQC as required by law.

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 found the lack of skills and knowledge exhibited by some staff who the management team had assessed as being competent, had placed people at risk of harm. We spoke with one staff member explained how they had received training to support people who displayed distress behaviours. They told us they had used restraint techniques at the service. This staff member explained they had completed training in appropriate use of restraint at a previous workplace and had done refresher training at this service. This staff member felt the training provided for them was sufficient for them to be able to support people as they required.

The management team could not demonstrate how processes in place at the service had led to continuous learning and improvement to enhance peoples’ outcomes. The registered manager had carried out reflective supervision and learning with individual staff where incidents or near misses had occurred. The actions from these had not been followed up to ensure care quality and shortfalls in staff practice could be improved. The management team had not ensured they had robust governance systems in place to deliver a quality experience, positive outcomes and good quality of life for people by ensuring care plans and risk assessments were contemporaneous. People’s rights under the Mental Capacity Act (2005) were not always being upheld by the service. The directors had failed to significantly improve the living environment for people to reduce the risk from fire, infection risk and environmental hazards. The management team had a service improvement plan in place to improve people’s care provision at Mount Vernon Terrace. This plan had not made significant progress to ensure this was always safe and effective for people.