231 Brook Lane

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

Improvements had been made following our previous rated inspection and our rating for this key question had improved to good. The governance of the service had improved. A new manager was in place and had made improvements to the service. Staff told us they were better supported since the new manager had started. They told us, they were confident the leadership team were committed to delivering a good quality service and promoted a supportive and open culture. Staff told us they had confidence in the skills and knowledge of their leadership team. The provider had a range of quality assurance processes in place, and these were mostly effective. This included audits of medicines, care plans and people’s environments. The provider had systems in place to develop the knowledge and skills of its current and future leaders and the manager told us they were supported by the provider in all aspects.

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.

Staff understood the manager’s visions and values for the service and were confident these would be achieved. Staff told us they felt able to speak up and gave us examples of this. A staff member told us they got feedback on learning from incidents or accidents. Staff told us they were confident their colleagues and the organisation promoted high quality compassionate care to people at all times. The manager spoke passionately about the provider’s vision and values. They described to us how the organisation’s values were embedded into the recruitment process to ensure values based recruitment was undertaken. They told us how they reviewed the culture within the service to ensure care remained person centred and staff morale was good. They shared examples of when they had challenged staff about practice through debrief sessions.

The organisation fostered a shared direction and culture among their employees. We reviewed evidence in the organisation’s recruitment processes of inclusion. When we reviewed people’s daily notes, we could see evidence of the organisation’s values being upheld. The manager was passionate about ensuring people lived the best possible lives which was in line with the organisation’s values. We reviewed evidence of the manager and the organisation challenging practice which was not in line with their values.

Staff told us the leadership team were capable, compassionate, and inclusive leaders. They had confidence in the skills and knowledge of the leaders. One staff member told us, “They are knowledgeable, especially the present manager. They know what they are doing and are trying to help improve the home and really trying to improve staff’s knowledge.” Staff confirmed the manager had a good oversight of risks. Staff told us, the manager is visible on a daily basis. One staff member told us, “Yes they are on site, and they come in at night to check on night staff, they came in 5 am one day checking we are doing all that we should be doing.” Another staff member told us, “Even when they are off duty you can ring or email them.” The manager told us what they wanted to achieve for people, they told us, “For the people who live here to have meaningful lives. For them to be involved in everyday decisions about their home. To have good quality lives, and to be respected.”

We were assured there were capable and compassionate leaders. We reviewed the organisation statement of purpose (SOP). The SOP contained the organisations aims and objectives, which included to help people make every day count, to work in partnership with families and commissioners and to be an excellent employer. The providers recruitment process was inclusive. The interview questions were based around the organisations values to ensure right from the start they were employing people with these shared values. The provider had taken prompt action to fill the vacant registered manager role and the new manager had started the registration process. The manager told us they were supported by their manager and the wider organisation. During the assessment process the manager was supported by the regional manager and quality lead.

Staff told us there was a culture of openness and transparency, they were confident in speaking up and were assured appropriate action would be taken. One staff member told us, “I feel comfortable to raise concerns and the new manager will action them.” The manager provided a safe space for staff to have the freedom to speak up. When asked what systems they had in place to ensure a closed culture does not develop within the home. They gave us examples of how they monitor this, which included completing ad hoc visits to the home, during the evening, early morning and at weekends.” They told us, they shared learning with staff through team meetings and debrief sessions where they discussed lessons learned and safeguarding. The manager gave us several examples of where they had investigated a concern. One related to a medicines error, where they had a 1:1 reflection with the staff member where they looked at barriers, impact and lessons learnt.

The provider was encouraging a culture of speaking up, being open, transparent, and learning when things go wrong. There were whistleblowing and safeguarding policies in place encouraging people and staff to speak up. There were also some accessible posters in the home. We reviewed a safeguarding tracker and were assured staff were speaking up and raising concerns. There was a duty of candour policy in place. We reviewed evidence of 2 occasions where practice had changed as a result of concerns being raised.

Staff told us their workplace was inclusive and free from discrimination. Staff confirmed they had access to policies and additional resources on discrimination and there were also support groups for staff. The manager had embedded a culture of workforce equality, diversity, and inclusion. They told us, “Policies and procedures are covered within the induction process. Part of the training informs staff where to find policies. The policies will also be located in our read and sign folder.” They gave as an example of when they made adjustments to accommodate a staff member.

We were assured the provider encouraged and promoted a workplace of equality, diversity, and inclusion. This was reflected in the provider’s equality and diversity supervision and appraisal policies . During supervisions staff well-being was discussed. The provider’s recruitment process was inclusive. The interview questions were based around the organisations values to ensure right from the start they are employing people with these shared values. The feedback we received from staff was positive with staff feeling able to speak up and raise anything with the manager.

Staff told us, they felt valued and motivated, were able to raise concerns, were asked for ideas on how to improve the service and team meetings were held regularly. One staff member told us, “Team meetings are once a month. We can speak up when we want to and before we have the meeting, we are able to add to a list of what you think should be discussed.” Another staff member told us, “If you can’t physically make it in, they will make provisions for staff to join online. You get the chance to raise any issues that you want during the meeting.” The manager was able to tell us, how they ensured notifications were submitted to the relevant agencies. They shared several examples when we asked how they involved people in making improvements to the service. One of the examples was a person choosing the soft furnishings and pictures for the area of the home they lived in. We asked the manager how they ensured good record keeping, they told us, “We comply with policies and procedures around good record keeping and GDPR. We archive and store historical information appropriately. Any sensitive information will be stored in a secure manner.”

Improvements had been made in the management and monitoring of the service. Stronger quality assurance systems had supported the provider to improve the service and meet all regulatory requirements. Quality and risk audits were taking place, and actions were highlighted to address shortfalls identified. However, there had been a delay in completing some of the audit actions such as IPC and staff files. The new manager was taking action to mitigate the risk of any outstanding actions. We were aware the service did not have a manager for a period of time prior to the current manager starting, however time was needed to ensure the provider strengthened arrangements to enable effective monitoring even in the absence of a dedicated home manager. We reviewed the business continuity plan which was detailed and included the information expected. Policies and procedures were mostly in date, reviewed when required and with the correct amount of information and detail. The manager told us, the policies which were overdue for a review were currently with their policy team for review. Team meeting minutes noted discussions were had about people being supported, incident forms, lessons learned, positive risk taking, expectations, safeguarding, training, audits, and communication. We noted contributions from the staff members attending to inform service improvements. Quality assurance surveys for people, their relatives and staff were mostly positive.

We received mixed feedback from relatives. We could not be assured all relatives felt the home collaborated with healthcare professionals in a timely manner.

Staff worked with various external agencies including, social workers, Local Authorities, safeguarding teams, and healthcare professionals. Relevant information was shared appropriately.

The provider was working in partnership with commissioners, other system partners and health and care professionals. “When I visited, it felt like the staff were motivated by the new incoming manager and were eager to improve the quality of support they provide. I was pleased with their support. They are respectful of my client’s life history and seem understanding of how it impacts them now.”

During our assessment, when we raised points with the manager, they were responsive and keen to get things right. They told us they had shared these points with the wider organisation to ensure they were also following best practice. Through reviewing information, observations and talking to staff and the manager, we could see evidence of the MDT’s involvement with the people living in the home. We attended a quality outcomes and contract monitoring (QOCM) meeting about the provider. In the meeting relevant health and social care professionals updated us on the improvements the service had made during the process. There was evidence of collaborative working.

The service was learning and improving. One staff member told us, “The manager is trying to make the home more homely with decorations especially in the lounge and dining area. For example, in the dining room there were no table mats or table cloth on the table, now there is, and it has been transformed. People notice a difference. There are also some pictures of the people being put into frames for them to see.” The manager told us, “I have shared the improvements I have made in person centred support and for when people have accessed their finances. I have shared a more person centred approach to completing MCA’s and best interest (BI) meetings.” They also told us they ‘‘I have long term plans about innovation, but right now it is re-introducing the basics and getting them right.”

The organisation was striving to learn and improve. We reviewed evidence in team meetings, audits and quality assurance surveys which assured us learning was embedded and the provider was continually striving to make improvements. The improvement seen during this assessment following the previous rated inspection had been vast and showed how hard the provider had worked to improve the experiences of the people living within the home, their relatives, and the staff team. The manager was new in post and was passionate and full of ideas and initiatives to improve the experience for all. They were extremely responsive throughout this assessment, to further learn and improve to ensure people were leading their best lives.