Montague Court

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

As part of this assessment, we looked at 4 quality statements for the key question of well-led. These were capable, compassionate and inclusive leadership, workforce equality, diversity and inclusion, governance, management and sustainability, and learning, improvement and innovation. Some staff were not clear of the aims of the service and how to achieve them. Managers did not demonstrate an oversight of the risks and governance systems, and these were not always effective in assessing and identifying risks to people who use the service. Systems to improve were not embedded in the service and were not based on the views of staff, the people who used the service and their families.

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.

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.

Some staff were not clear of the rehabilitation aims of the service and how their role helped to achieve them. Staff said that managers were visible and approachable.

Leaders did not proactively take action to review and improve the culture of the organisation. Managers did not demonstrate an oversight of the risks and governance systems and how they identified the risks to patients, staff and the environment.

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.

Occupational therapy staff understood the culture of the service in the context of equality, diversity and inclusion. They showed us how they planned to incorporate information about people’s protected characteristics in their care plans. However, some nursing and support staff were not aware of this and how it related to people’s care planning. Staff were not involved in ideas to improve the service.

Leaders were working towards the delivery of safe, effective and inclusive planning and delivery. But this was not always clear. The manager did not have a full understanding of all processes and policies pertaining to equality, diversity and inclusion or their impact. Staff meeting minutes showed discussion about protected characteristics and staff were asked to update all care plans going forward to incorporate these. Staff received on line training in equality and diversity and protected characteristics. A staff survey was conducted in July 2023 and only 14% of staff responded to the survey. A follow up survey was scheduled in March 2024. We were not provided with the response from this as this was being reviewed at the time. One of the actions from the survey in 2023 was to reintroduce ‘staff away days.’ Managers planned this for June 2024. The last survey for people using the service was in 2021. There was no evidence of a friends or family survey.

Managers told us about governance processes and how information was fed back to the quality governance board. Some staff were not aware of processes to identify learning and how outcomes of audits made improvements to the service.

There were some effective governance, management and accountability arrangements. However, these were not always effective in identifying and assessing risk to people who use the service. The manager did not have an overview of the risks at Montague Court and what was on their risk register. Managers had identified that staff needed training in National Early Warning Scores (a tool that measures the degree of a person’s illness and prompts intervention where needed). This was provided the week before our visit so the impact of this was not evident. Audits were completed but did not show actions identified had been taken. The ligature assessment showed that three actions were in progress but there was not a date for action to be completed. Infection control audits showed that new staff had not completed hand hygiene or food safety training but there was no evidence of when this was planned. A list of incidents for the quality governance board meeting was made but there was no evidence of discussion of these and no plan to reduce further incidents. However, following, a CQC Mental Health Act Reviewer visit in February 2024, leaders had shared feedback with staff. This included documentation of informing people of their rights, informing their relatives, recording capacity assessments and how to meet their cultural needs. This was discussed in the staff meeting on the 25 March 2024 and proactive steps to address any concerns were shared with all staff. Leaders did not have oversight of the quality of care being delivered. There was not a system in place to monitor and improve care and treatment.

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.

Staff and leaders did not have a good understanding of how to make improvement happen. Leaders tried to encourage learning, but this was not shared with all staff. Staff were not aware of how action was taken to improve the service.

There were processes to ensure that learning happens when things went wrong, and form examples of good practice. However, these processes were not embedded in the service to ensure improvements are made across the service. There was no evidence of strong external relationships that supported improvement and innovation. No additional evidence of positive or innovative practice was provided. People using the service, their families and carers were not involved in developing and evaluating improvement initiatives.