Malsis Hall - Mental Health Care Home with Nursing

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

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Leaders had a clear plan and direction of improvement which was shared with staff. The provider had worked hard to recognise areas for improvement and have been working with staff and stakeholders to take action to improve. The improvements had been recognised at this assessment where improvements were clear. One leader told us, “We have worked hard to improve, and we have an action plan tracking the improvements we have made.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were capable and experienced to drive change. Leaders at the service were visible and had expertise and a passion to drive change and improvement to ensure people received high quality care. Staff felt leaders were fair and credible. One member of staff told us, “The managers are excellent. The managers are what make it good to be here.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and people felt able to speak up. There was an open and transparent culture which welcomed feedback and challenge. Leaders worked in partnership with people, advocates and staff to understand the views of others and took the necessary action to put things right. One person told us, “I would know what to do to if I needed to complain. I would go to the manager if I had to.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders had a focus on diversity and inclusion. Leaders fostered a culture of acceptance and embracing different cultural beliefs with the staff team and people using the service. Protected characteristics were understood and plans put in place to ensure there was a zero tolerance to discrimination.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had an oversight of the quality of the service. Leaders at the service regularly met with the provider to discuss incidents, risks and improvements needed to ensure accountability and transparency. Successes were celebrated with the staff team and areas of improvement and positive changes were shared with the staff team. Leaders maintained oversight to ensure their changes had embedded.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

There was a strong focus on working with community groups and partners. Staff and leaders ensured people had access to the health and social care support they needed, when they needed it. The provider worked with local community groups to facilitate sporting events within the grounds of the service to benefit the local community and integrate people who used the service with their local community.

While provider recognised continuous learning, innovation and improvement across the organisation and local system were needed to consistently ensure documentation as completed to a high standard, improvements were still needed to embed good practices.

Improvements were needed to ensure consistency of quality across records and the management of medication. While we found some records were high quality, person centred and up to date, this was not consistent across all records. This included care plans, risk assessments, de-briefs, consent, mental capacity assessments and best interest decisions. While improvements had been made since our last assessment of the service in this area, further improvements were needed. The provider was aware of the outstanding improvements required and they had a clear improvement plan in place to drive and embed the changes needed.