Archived: The Branches

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment this key question has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The provider was in breach of the legal regulation relating to good governance.

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.

The management team had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The change in management had led to some unsettlement. The new management team were focussed on continuing to improve morale within the staff team.

The management team were capable and experienced but were yet to put into practice updates in procedures to address concerns they had identified, or those we had during our inspection. The provider worked with integrity and was open and honest. Some staff missed the previous registered manager who had worked at the service for many years, while others accepted changes were needed to bring the service up to date and in line with best practice. One staff member said, “We are like family. Families have hard times, but we are all here to support each other and the priority is our residents, it’s about them.”

The management team fostered a positive culture where people felt they could speak up and their voice would be heard. People felt confident to speak about anything with staff. Staff felt their views and suggestions were now being taken on board, although some staff had been reluctant to the changes needed. One staff member said, “I love coming to work. I really enjoy my job and feel like the manager and owner really care.”

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. The provider valued diversity and ensured they followed best practices guidance.

The provider did not have clear, effective systems of accountability and good governance. There were a range of checks and audits in place, but these had not always identified or addressed the issues we had found during the assessment, especially those in connection with medicines and infection control. The provider had already purchased a quality assurance system and were going to review this as part of required improvements.

Care records were still in the process of being reviewed. We found some monitoring records not being utilised fully. This included food and fluid charts and behaviour charts. We discussed this with the provider, and they assured us action would be taken to improve in these areas.

There was no registered manager in place at the time of the assessment. The provider had appointed an interim manager who was yet to register. The provider also needed to apply to update their registration.

The provider and staff understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Healthcare professionals were positive about the care being provided by staff. They commended them for their compassionate and caring approach. One said, “The care is second to none.”

Care records were still in the process of being fully reviewed to make sure they were up to date and accurate when sharing details between services.

The management team were now focusing on continuous learning, innovation and improvement across the organisation and local systems. This included focus on improving the Wi-Fi system in the service which had poor reception. The provider took on board feedback given during the inspection visit and was keen to implement suggestions made for improvement. These improvements needed to be maintained and closely monitored.