Collingwood 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

We identified 1 breach of the legal regulations. The governance system needed to become more robust to identify where improvements were needed to care provision, as identified at inspection, to ensure the improvements were brought about in an effective and timely way. Several improvements were being made by the new manager however improvements were required to the management of risk, staff deployment, medicines management, records and governance to ensure the safety of people who used the service. We received some comments from relatives and staff that communication needed to be improved. People, relatives and staff were very complimentary about the changes being introduced. A relative commented, “The new manager has revolutionised the place. Every time I come in I see some improvement.” Since the last inspection the previous registered manager had left the service. Moving forward, there were plans for split management of the home with the registered manager of another service also being responsible for part time management of Collingwood Court, therefore they would not be on site for day-to-day management over 5 days. A relative commented, “The new manager is a lovely person, although I think they work across 2 care homes.” The manager promoted a positive culture which was practised and promoted by the staff team. People and staff said they were not afraid to speak up and they knew they would be listened to. A person told us, “You can take your concern to the manager, and they will do something about it and follow it up.” People, their relatives and staff were asked for their views and experiences of the service. Feedback was listened to and addressed. There was a capable and compassionate management team who, with staff, worked to ensure good quality outcomes for people in partnership with external professionals. Staff told us they felt supported by the management team.

This service scored 62 (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.

Staff and leaders shared the values and vision of the organisation. New staff received support and training which helped them to show those values in their daily work with people. There had not always been a positive culture, but since the new manager had come into post staff told us there was improved team working and they felt supported by colleagues and management. Their comments included, “There is good teamwork between all staff, especially over the last 2 months, there is a much better atmosphere”, “I love working here, it has felt very comfortable, everyone has been very welcoming. I have received good support from everyone”, and “Teamwork is excellent, improving daily, staff work together for the benefit of the residents.”

People and staff felt able to speak up to management. The management team worked to ensure there was clear understanding of the values and philosophy of care provision shared by all staff. Systems were in place to ensure people and staff were involved and listened to. New staff received support and training which helped them to show those values in their daily work with people. The quality and vision of the service was regularly discussed with staff during a range of meetings. The positive service culture was promoted by leaders and staff.

Staff and people said they had confidence in the management team and would not be afraid of raising any concerns. They confirmed they felt listened to. A staff member commented, “The management team very responsive to any ideas, I feel heard, and all ideas/suggestions are considered.”

Processes were in place for staff and people to speak up. The provider had a clear whistle blowing policy. Staff could raise concerns and the information about how to do this was available in the service and within the staff handbook. There were engagement surveys sent to people using the service, and staff. Staff meetings took place. There was a complaints procedure. Staff and people said they had confidence in the management team and would not be afraid of raising any concerns.

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 and leaders knew their responsibilities around quality and safety monitoring and governance. The manager and senior staff could explain governance systems in the service and their individual responsibilities, however there were areas of improvement identified at inspection as previously described in the safe section of the report. The manager made some immediate changes as a result of our feedback, however the improvements made needed to become embedded and sustained.

We identified 1 breach of the legal regulations due to some concerns and failures in the monitoring of service provision and improvements needed to some systems, records and medicines management, detailed in the safe section. We discussed with the manager that some records of daily interventions such as food and fluid intake, positional and personal care interventions and medicine administration records were completed retrospectively by staff rather than at the time of the intervention. This meant recordings may not always be accurate and may not provide correct information when monitoring a person's well-being. There was oversight from the provider to review the quality and safety of the service in line with regulatory requirements, with quality checks carried out by the compliance team, however these were not always effective. Other audits and checks were carried out such as around the environment, infection control, care records, health and safety, staff practice.

People and relatives told us the service worked with other agencies so people could access appropriate help and support when required. Their comments included, “The staff could not do a better job. The district nurses come in to do the dressings [Name]”, and “Staff are really hot at picking up on infections. They contacted the GP who has involved us as a family.”

Staff and the manager explained how they worked with healthcare, social care and community partners. They had good knowledge of the local services and support systems and how to access them. There was weekly clinic held by the GP at the service. Referrals were made in a timely manner to relevant people to ensure the needs of the people using the service were met. There was some evidence that the manager had a willingness to work with partner agencies.

We did not receive any feedback from partner agencies relevant to this quality statement.

Management and people’s records included communication with partners such as healthcare professionals, social care teams and specialist services. The manager ensured the service was aware of their local systems, so staff could work well with partners.

Staff told us there were opportunities for training and development. A staff member commented, “We do face to face and online training.” When speaking with staff and leaders we were not assured that there was an effective process of reflection and lessons learnt following incidents. Individual incidents were reviewed but some kept recurring.

The provider had systems in place to ensure learning and improvement was considered within audits, staff meetings and quality assurance activities. There was evidence of improvements that had been made to the service as a result of the checks, audits and some people, relative and staff feedback. However, processes to ensure that learning happened when things went wrong, and from examples of good practice were not well- established. There was not a clear strategy within the service of lessons learned and evidence of improvement regarding, for example, medicines management and other areas of concern such as the management of falls.