Daleside 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

We assessed 7 quality statements in the well-led key question and found areas of concern. The scores for these areas have been combined with scores based on the rating from the last inspection, which was good. Our rating for the key question has changed to requires improvement. The service was not always well led. We identified 1 breach of the legal regulations. The registered manager did not always demonstrate there was an inclusive and positive culture of continuous improvement. There had been delays in reporting of events which occurred in the service to other agencies, including the CQC. The governance systems had not been effective in identifying improvements. Audits completed failed to identify all the issues we shared throughout this assessment. Family members did not feel consulted with or feel their views on the service were heard. There was a lack of family meetings or other ways of seeking feedback on the service from people such as surveys. The provider did have a clear vision for the organisation. Staff did feel confident to speak up if there were concerns about people’s care. Policies and procedures supported workforce equality, diversity and inclusion.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The regional manager discussed the visions and values of the organisation and explained how staff were encouraged to work in line with these. However, they were not aware if people had been involved in developing these. They told us how equality and diversity was promoted through promotion of a diverse workforce, right to speak up and an open-door policy for people to raise any issues. Staff we spoke with were not all able to describe the vision and values of the organisation, nor how it applied to their role.

The providers vision and values statement was displayed in the reception area of the service. The provider had a service user guide. This outlined the core values as privacy, dignity, independence, choice, rights, fulfilment. Our assessment found evidence some aspects of care fell short of these values. The provider had appropriate policies in place regarding equality and diversity to avoid and address potential workforce inequalities. The regional manager recorded their conversations with people who resided at Daleside Nursing Home and family members during visits. This demonstrated a provider commitment to a listening culture within the service.

Staff told us they felt well supported by the registered manager as well as by the wider management team. The regional manager told us the company encouraged progression amongst the staff and promoted professional development by offering staff the opportunity to achieve professional qualifications.

We identified several failings which have resulted in several breaches in legal regulations. There was a lack of awareness or action by the service’s management team of many of the concerns we identified and raised. The registered manager was not ensuring high quality care was being delivered across the service.

Staff told us they were confident to speak up about poor practice. They felt they could approach the management team and felt confident their concerns would be treated seriously and acted upon.

The provider had appropriate whistleblowing procedures in place. We did find shortfalls in relation to duty of candour. We noted several events which occurred had not been responded to in a timely manner. This meant people were not always aware something had gone wrong and had not received the apology and acknowledgement in line with the providers processes. The registered manager told us they had informed people and their family members, but this was not always recorded.

The regional manager was able to describe the process they would follow if concerns were raised. They were able to provide examples of how staff members with protected characteristics were supported. This included considering reasonable adjustments to enable staff members to fulfil their role.

The provider had appropriate policies in place to support workforce equality, diversity and inclusion. The provider did not have a formalised workforce wellbeing plan however, the human resources manager told us this was a piece of work which was being planned.

We spoke with a senior care worker who was able to describe the governance processes followed when a new person moved into the service. The deputy manager also described the process to maintain oversight of peoples nursing needs. They told us the registered manager led clinical governance meetings monthly. We were only provided with one copy of such a meeting which was dated January 2024. We discussed this with the deputy manager and the registered manager who were unable to provide evidence this meeting had been completed monthly.

Quality assurance systems in place had not always been effective in ensuring areas for improvement were identified and addressed. For example, care plan audits had been completed on the care plans reviewed, but the issues we identified during this assessment with records being inaccurate, risks not being reviewed and a lack of consideration of the MCA had not been identified. Routine checks which should have been completed by the registered manager to ensure oversight of individual risks were not routinely completed or recorded. The provider used a resident of the day system to review peoples planned care. This was not consistently completed. Whilst risk assessments and care plans were reviewed as part of this process, there was no evidence this review looked at the quality of the care plans, or that it was used as an opportunity to engage with and seek people’s views on their care. Prior to our assessment visit the provider had identified improvements were needed at the service and had strengthened the onsite support for the registered manager and senior team. We were shown a detailed improvement plan which had already been developed. This provided us with some assurance there were plans in place to address the quality of care provided.

People gave us mixed feedback about whether they were able to access other agencies to ensure aspects of their care were met. One person shared an example of paying for but then waiting for a chiropodist to come to the home. A family member told us they had to access a GP themselves on behalf of their relative as the staff had not taken prompt action.

The nursing and senior care team were able to demonstrate how they were working collaboratively with health professionals. For example, the deputy manager was knowledgeable about the different services they would link in with to meet people's needs. They gave examples of partnership working when reviewing accidents and incidents. For example, making referrals to the fall team, GP or safeguarding team.

Prior to our assessment we received feedback from the local authority. This included concerns about a lack of engagement by the registered manger to support effective partnership working. The local authority was undertaking a series of quality visits and were in regular communication with the service to improve this.

Systems were in place for the provider to demonstrate when partnership working had taken place. This was recorded via the regional manager quality visits and evidence the reason why this collaboration took place. The registered manager told us they attended local provider forums to learn and share best practice tips from the local area. The provider had sought input from an external consultant agency who had completed a ‘mock’ CQC assessment. The most recent report had generated actions to improve the service however, limited progress had been made at the time of our assessment.

The experience of staff was varied around whether there was learning from events which occurred. For example, not all staff were invited to debriefs or had learning shared with them following incidents. The provider was open and transparent throughout the assessment and was open to the feedback given and demonstrated a commitment to making the improvements needed at the service.

The Statement of Purpose document shared with people and their families stated there would be opportunities to engage and offer feedback about the service. This had not been happening. The improvement plan for the service confirmed there have been no resident or relative meetings since November 2023. There had not been regular team meetings for staff to attend and their share views about the quality of the service. We received an update from a social worker which confirmed the management team had arranged a family meeting since our visits to the service. One family member had confirmed they had been asked to fill in a survey to gather their views on the service and been asked to contribute to developing their relatives care plan.