Mount Olivet Nursing 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

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 in 2023 we rated the well led key question as requires improvement.

We assessed all of the quality statements within this key question. At this inspection, the rating remained requires improvement. This meant there were shortfalls within the services governance systems. We found a continued breach of regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff and the registered manager had a positive, compassionate listening culture that focused on learning and improvements. However, the service did not always have a formal process to monitor improvements. For example, in relation to ensuring actions had been followed up after an audit had identified improvements needed. This is described in the learning, improvements and innovation quality statement in well led. Staff told us they were always looking to make improvements within the service. One staff member told us, “(Registered managers name) tries her best and if you want to speak to her she is always approachable and she is a good manager and always improving things.”

The service adhered to its aims and objectives, as set out in its statement of purpose. This included providing a service that, “Enables residents to live independent and fulfilled lives as far as they are able, with dignity and privacy in a tranquil and elegant environment.” The registered manager and provider had a clear vision and strategy which had people at the heart of the service which staff understood and worked towards.

The management team told us about how they encourage staff to gain additional skills and knowledge. They told us how they supported staff to become champions in different topics, such as, staff induction, infection control and moving and handling.

One staff member told us, “I would say the management do support and encourage us to develop. They encourage us to do more training like some carers want to do medication training or want to move up the ladder to be a senior, so that offer to improve is always there.” The registered manager told us about the groups they are involved in to support the registered manager to keep their knowledge up to date. For example, 1 group was for sharing good practices between different professionals within social care.

The registered manager adopted an inclusive leadership style. They had regular leadership meetings with heads of departments to understand any challenges or risks in delivering care and support to the people living at the service. This allowed them to work together and reduce risks. The provider completed regular checks of the registered manager audits and the running of the service. The provider gave feedback to the registered manager.

External partners we spoke with found the registered manager to be open and honest.

Staff told us they felt able to raise concerns without any fear and felt the registered manager would deal with concerns appropriately. One staff member told us, “We do have regular supervisions, it is every 6 months and then the annual appraisal with (registered manager name), and staff meetings they happen every couple of months but if we have any issues or concerns, (registered managers name) is very approachable in the meantime.”

The provider had a whistleblowing policy in place. Relatives and people using the service could provide feedback through an online webpage.

We saw evidence of staff meetings. We saw staff and some residents' feedback from the provider’s review audits, employee surveys, and resident surveys. The service told us they did not receive many survey responses from visitors. We saw one health professional feedback, and we were not provided with any survey responses from relatives. People we spoke with did not highlight any issues with raising concerns. The registered manager also had an open-door policy for staff, people, relatives and health professionals to provide feedback.”

Staff did not highlight any concerns around discrimination or bullying within the service. A staff member told us, “It is just a very nice home and a nice team and we are running a lot like a family, the residents are loved and we are friendly with the families.”

The registered manager told us about specific topic themed days which included people living at the service and staff. These themed days allowed a safe place for staff to speak about the theme/topic, such as menopause and its effects. Staff felt included and listened to. This helped to improve their knowledge about the theme and understand that everyone may be going through different things in their life and the team were there to support if needed. The service had identified topics to promote workforce equality and diversity.

The registered manager told us about and understood their responsibilities in relation to notifying the Care Quality Commission (CQC) of notifiable events. However, we found not all of these events had been reported to us. For example, in relation to submitting notifications, as described in the safeguarding quality statement in safe.

We discussed this with the registered manager who submitted some of these notifications retrospectively. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to good governance.

There were improvements in relation to safe care and treatment, but further improvements were needed, in relation to consent to care and treatment and governance.

The provider had systems and processes in place to identify inconsistencies within care records, such as the provider audit. The provider had identified some areas of improvement within people’s records, however, the concerns we found following our assessment had not been identified. Such as where people lacked capacity to make informed decisions, or give consent, the service must act in accordance with the requirements of the Mental Capacity Act 2005, and the service must maintain accurate, complete and contemporaneous records in respect of each service user.

Most of the records we reviewed, we found were not always accurate and contemporaneous. These records provided staff with some inaccurate guidance on how to care for a person, putting the person at risk of harm. Whilst we did not identify anyone who had come to harm, this contributed to the continued breach of regulation in relation to good governance.

People and their relatives told us the service would contact medical professionals when needed. People told us, “They (staff) would call the doctor if I asked, or if I’m not feeling well.”

The registered manager told us about different circumstances where they would work with professionals to ensure continuity of care. For example, the registered manager told us about specific equipment they had purchased to support with monitoring and managing a treatment a person was receiving from their GP. This process was less distressing for the person and ensured changes to the person’s care and treatment were accurate and prompt.

Health professionals we spoke with were positive about the service. One health professional told us about working with the registered manager to support a person living with diabetes which resulted in a better quality of life for the person.

There were systems and processes to maintain effective communication with people’s GP’s to identify and escalate risks to people’s health and wellbeing. Staff maintained records of interactions with external professionals and follow-up actions taken after referrals were made. We observed information was being passed to a person’s GP allowing joined-up care.

The registered manager told us about different ways they communicated learning and improvements to staff. For example, through team meetings, newsletters and/or 1-1 conversations. Staff confirmed there were different ways the leadership team would communicate with them. One staff member told us, “We have a home WhatsApp group to keep us all updated. We also leave notes on whiteboards and we have handovers at the start of every shift.”

The registered manager worked with staff, people and their loved ones to build a culture that focused on enabling people to enjoy a full life. The registered manager did not have a formal action plan to prioritise improvements and ideas. When we met with the management team we discussed the service needed to review their process to ensure improvements that had been identified through audits were clear, stated a timeframe for completion and who was responsible for making these changes. This was to ensure these improvements are monitored and completed in a timely way.