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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 identified a breach of regulation during this assessment of Well led. Governance and oversight systems were not always effective, and we identified concerns relating to environmental risk, accident and incident oversight, safeguarding concerns not always reported appropriately, medicines and oversight of deprivation of liberty applications and authorisations as described in other areas of this report. The senior management responded proactively to the concerns identified during this assessment. However, at our previous inspection a recommendation was made for the provider to review their systems and processes for quality assurance to ensure more robust oversight of the service. The quality assurance processes in place were still not effective as shortfalls found during this assessment had not been identified by the provider. Whilst improvements were needed to ensure effective oversight people, relatives and staff were positive about the way the service was run and the support they received.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they were happy working at the service and the culture was positive. A staff member told us, “The morale here is quite good, we all have a bit of banter between us, we all know our routines and what we have to do.”

The registered manager was hands on at the service so knew people and staff very well. Throughout the assessment we observed their continued interaction with people and their relatives. They were passionate about ensuring people’s rights were upheld and they had access to other relevant agencies when needed. A professional told us, “The care staff are really good. I have never had to raise a concern; they are very cheerful. They also are proactive to contact us to gain support.” As recorded within this well led section some improvements were required in relation to oversight to ensure any risks to the organisation were fully explored and mitigated.

The registered manager and deputy manager were very visible in the service. Staff told us the atmosphere in the service was positive and they were supported in their role. A staff member said, “It is a good place to work, the best things are the people, it’s like one big family. We have a laugh with residents and their families but professional when we need to be. The resident’s families are part of us we all get on. I feel very supported.” Whilst the senior team were supportive and accessible, some improvements were needed in relation to oversight of the service.

Whilst we saw the leadership team were very supportive to people who used the service and staff, some additional learning was required to ensure all aspects of the service was being monitored.

Staff told us there were processes in place to speak up and they felt confident any concerns escalated to the management team would be actioned. A staff member told us, “The [registered manager] is a very nice person. They listen to us whenever we go to them. At staff meetings, we can speak up and are free to talk. I wrote down about checking the residents’ pockets [prior to washing] at the meeting and action was taken.” Another staff member said, “[Registered manager] looks after us as well as the residents. Any problems we can share, and we are listened to.”

There were processes in place for staff to speak up, these included supervision sessions, appraisals and staff meetings. The whistleblowing policy was on display in a staff area and staff told us they would use it if needed. People and relatives told us communication with the service was good and they were informed about any concerns affecting them or their family member. A person told us, “I would go to speak to [registered manager] if I needed to speak up about anything or complain. A relative said, “They contact me straight away if there has been fall. We identified more work was required to fully investigate all incident and accidents and escalate these to relevant agencies.

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.

Staff were positive about the management team and aware of their responsibilities. A staff member said, “It’s like one big family. We have a laugh with residents and their families but professional when you need to be. The resident’s families are part of us we all get on. The registered manager responded appropriately to the concerns we identified during this assessment. The Deputy manager told us they had booked additional safeguard training for staff.

Governance processes required improvement. Whilst checks and audits were in place, they were not effective in identifying the concerns found during this assessment. Whilst the registered manager responded to our concerns and took action, the checks and audits had not picked up the concerns identified and described in this report. Improvements were required in areas such as environmental risk, safeguarding reporting, medicines, accident and incident investigation and DoLS.

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.

The registered manager was working to improve the environment and we saw refurbishment work taking place in vacant rooms. Staff were positive about the training they received and told us meetings were used to share information with them for future learning.

We identified some improvements had been made and some recommendations made at the previous inspection had been actioned. However, more learning was needed to ensure audits and checks incorporated all areas of the service. Whilst people and relatives told us they were happy with the care and support they received, more work was needed to ensure record keeping and oversight was robust.