Surbitonian Gardens at Poppy Court

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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

The provider had clear governance and management systems in place as well as systems to manage current and future performance and risks to the quality of the service. There was a new management team in place who had implemented changes to ensure good care delivery for people. At the time of our assessment, the provider had been delayed in sending safeguarding information to an external organisation as required, but the management team demonstrated learning from this to ensure there was no repetition. The provider did not always ensure that people using the service and their families were involved in developing and evaluating improvements within the service. This was because there was no system in place to obtain consistent feedback from all people and their relatives. Staff told us they were able to approach management and were confident issues would be dealt with.

This service scored 75 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

There was a new management team in place with shared responsibilities to ensure good care delivery for people. The managers appeared experienced and knowledgeable about their role, expectations and legal requirements. They were committed to making a change at the service as well as improving the quality of the service being delivered to people. The service manager told us, "I want staff to be empowered. We don’t just tell them what to do, we tell them what and why we do it. Every single level has clear expectations as we can't do everything ourselves. We explain the rationale and the framework we work towards."

The provider had clear governance and management arrangements in place. At the time of our assessment, a new manager and deputy manager had been appointed and there was a clear structure, including clear accountabilities for staff within the organisation to ensure the continuity of care. The new management team were also supported by senior leaders within the organisation to ensure they were supported into their roles. There were clear systems to manage current and future performance and risks to the quality of the service. The provider conducted a range of audits in areas such as medicines management and infection control to ensure issues were identified and rectified. Action plans were in place and we saw these had been implemented according to the provider’s deadlines. The provider had business plans in place for the ongoing improvement of the service and plans were in place to ensure this. At the time of our assessment, the provider had been delayed in sending safeguarding information to an external organisation as required. However, the provider had demonstrated learning from this incident and there were systems in place to ensure notifications were submitted to external bodies, including the CQC, as required. Data was kept in a protected format to safeguard its integrity and confidentiality.

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 were able to approach management and were confident issues would be dealt with. Staff comments included, "Oh yes, we talk to managers if any issues. The managers are very open. First, we talk to the team leaders, they resolve issues most of the time so no need to talk to the managers. Managers listen. They are amazing people to talk to. [Name of the deputy manager] is very approachable" and "I see that managers are putting efforts ensuring things are done. Staff are now working in one unit which is good and they had done that. I would applaud them for doing better and better and improving things here. I believe in the new management and what they are doing." The service manager told us about the new processes being introduced making sure staff were performing in their roles to the required standard. This included regular meetings being carried out to discuss issues arising and additional training being provided for the staff team to improve their skills and knowledge as necessary. The service manager said, "We are aiming to lead, coach and support the management team making sure they perform their responsibilities. We can't do everything ourselves. Building the trust with the team is important."

The provider did not always ensure that people using the service and their families were involved in developing and evaluating improvements within the service. The provider held meetings with relatives on a quarterly basis and obtained their feedback in relation to a number of areas. However, there was no system to obtain feedback from all relatives, for example through surveys or conducting questionnaires to ensure all relatives were involved in service improvement. The service was working to develop its external relationships to improve the service. Staff and leaders were in the process of working with external providers of services to understand areas that require improvement and working with partners to plan improvements. The provider implemented a number of measures to improve the service and ensure lessons were learned. The provider conducted group supervisions with staff following incidents, including safeguarding incidents or monitoring visits. Reflective sessions were held and minutes were kept. These demonstrated that staff provided their views and honest discussions were held about how improvements could be made and lessons could be embedded.