Stainsbridge House

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• 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 reviewed 7 quality statements for this key question. Leaders were heavily involved in the service on a day-to-day basis and were committed to providing a good standard of care. There was a strong, supportive culture within the home. Equality and diversity and people’s rights were promoted, and leaders encouraged anyone to speak up if they had concerns. These were addressed in a timely manner and used to improve practice. Leaders and staff worked well with other professionals and enabled people to be part of the local community. However, whilst audits were completed in line with the provider’s schedule, not all were effective. This was because shortfalls found at this assessment, including in relation to care planning and record keeping, had not been identified.

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.

Leaders told us there was a strong culture of promoting people’s rights. This included making sure the environment was homely and comfortable, and respected as each person’s home. Leaders told us they spent much of their time building relationships and observing practice, to ensure the home’s values were being implemented. Staff confirmed this. They said each team member was focused on the person to ensure their wellbeing. Staff told us leaders were approachable and could be spoken to at any time. This enabled a supportive and cohesive culture.

Values and visions of the service were shared and adopted by staff. Leaders spent time with people, relatives and staff to promote role modelling and enable views to be shared. The view of the service being the person’s home was visually promoted. This included a selection of hats on a coat rack, and colourful letters spelling ‘This is your home’ on a white board in the main corridor. There was a policy to describe the home’s direction and culture.

Staff gave positive feedback about leaders. They said they were ‘caring’, ‘amazing’, ‘approachable’, ‘organised’ and ‘always available for advice and support’. This included taking time to discuss any challenges in their personal lives, as well as those work-related. Staff said leaders helped out where they could, so were aware of any challenges experienced. Leaders told us they saw this as being an important part of their role, rather than being isolated in their office. They said they wanted people’s experiences to be good and were passionate about ensuring this.

There were regular meetings, supervision sessions, appraisals, handovers and informal discussions to support staff. These forums enabled information-sharing and positive relationships to be developed between leaders and staff.

Leaders told us they had an open-door policy and encouraged any concerns to be raised at the time. They said they promoted an open culture, as they wanted any shortfalls to be raised confidently, in a timely manner. This ensured prompt resolution and improvement of the service. Staff told us they would raise any concerns with leaders and were confident they would be listened to and taken seriously.

There were systems to encourage people, relatives and staff to share their views about the service. This included a speaking up policy, meetings, surveys and a suggestion box in the front entrance. Records showed all suggestions were considered, and action taken where possible. However, the information did not demonstrate people were told about the outcomes of their feedback. Leaders confirmed there were no current systems for feedback, but said in future, they would incorporate any improvements made into the home’s newsletter. This would enable people to see their views were valuable and used to enhance the service.

Staff told us the team was very supportive of equality, diversity and inclusion. They said this was shown by the staff team having different skills and experience as well as different ages, genders and nationalities. Staff told us they had completed online equality and diversity training.

There was an Equality and Diversity policy and training formed part of the provider’s mandatory training programme. There was a supportive culture and staff were encouraged to raise any challenges they were facing at work. These were discussed with amendments made as necessary.

Leaders told us they regularly walked around the home to check the environment, care delivery and people’s care records. They said there were also regular audits undertaken at scheduled frequencies to check these areas. Staff told us leaders had clear oversight of the home and were passionate about providing a good, well managed service.

Quality auditing was undertaken but systems were not always effective, as not all shortfalls identified in this assessment had been identified. For example, it had not been identified care planning to help staff manage distressed behaviour or a person’s epilepsy was limited or that risk assessments were not always updated in a timely manner. Audits had also not identified subjective language such as describing a person as ‘was confused’, was being used in care notes or that the information was not always an accurate portrayal of events, or the care provided. This included a care record which stated, ‘Fighting with [name of person]’ even though staff immediately intervened and de-escalated the situation without there being any physical contact. Accidents and incidents were reviewed every three months, but there was limited analysis of themes or trends documented. This meant the service was not able to identify ways to minimise further occurrences. Action plans had been devised following some audits, but the format did not always show when the actions had been completed. This did not allow for adequate oversight to ensure improvements were being implemented. Leaders from other services related to this service assisted with auditing and whilst some shortfalls were identified, others as found at this assessment had not. There was a schedule of auditing including each area and frequency. This was being complied with.

Relatives told us their family member received support from the GP or District Nurse as required. They said people interacted with the local community and were supported to attend different events within the town.

Leaders told us they had developed good relationships with all health and social care professionals involved in people’s care. This included the care liaison team, district nurses and GPs. Leaders told us they had a team of volunteers who provided valuable time with people. Staff confirmed this and said they promoted contact with the local community. This included supporting people to attend events in the abbey or the town’s carnival.

Health and social care professionals we spoke to were complimentary about the home and the staff team. They said leaders were organised, and there was good communication. Health and social care professionals told us they felt people using the service were kept safe, and staff had requested specialist advice when needed, in a timely manner. They said staff were always able to answer any questions about people and followed instructions well.

Partnership working regularly took place to meet people’s needs. This included work with the local care liaison team to help staff lessen people’s anxiety. Leaders attended forums, meetings and workshops to gain advice and knowledge from others. This included local care provider meetings and regulatory forums. This included an understanding of CQC’s new way of working, including the new Quality Statements and a focus on risk.

Leaders told us learning and improvement was important to them. They said they wanted to ‘get it right’ and would immediately address any shortfall or concern raised with them. Leaders told us they were in the process of improving the environment for people. This had involved researching different colour schemes and the impact on people living with dementia, before any work was decided upon. Leaders told us they regularly asked for feedback about the service and suggestions were implemented where possible. Leaders told us systems to ensure people were informed of any action taken would be developed.

Leaders regularly met to discuss the future development of the service. This had resulted in a refurbishment plan to develop the environment and enhance people’s well-being. Suggestions from people and their relatives were discussed and implemented to enhance the service. This had included the development of the garden and regular deployment of a gardener. An electronic sensory device, known as a magic table, had been purchased to enable activity and added stimulation for people. This was on during the assessment and watched by those people walking by. Other leaders within the organisation were deployed to audit the service and identify improvements needed.