Sunbury Nursing Homes

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 the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. Leaders promoted a culture based on openness, inclusion and person-centred care. Leaders had established a clear vision and values which focused on safe and person-centred care. Staff were able to explain how their roles contributed to providing care and supporting positive outcomes for people.

There was a positive and inclusive culture across the service. People, relatives and staff spoke positively about the leadership team, describing leaders as visible and supportive. The registered manager worked closely alongside staff to maintain a visible presence. This enabled them to understand people’s individual needs and changes in their health and wellbeing. People and relatives described positive experiences of care and felt staff knew them well.

Oversight of the service was strengthened by other senior leaders who regularly engaged within the service and monitored performance. They worked collaboratively to drive continuous improvement. Staff told us they felt valued and supported by leaders.

Leaders promoted an inclusive culture and understood the needs of people, staff and the service. People, relatives and staff spoke positively about leaders and described them as approachable and supportive.

There were systems in place for audits, supervision and provider oversight. Leaders used these to identify risks and areas for development. Leaders encouraged staff to reflect on practice and supported learning. Staff told us leaders supported their professional development and encouraged them to increase their knowledge and skills. This enabled them to provide guidance and support their colleagues, promoting good practice and improving outcomes for people using the service.

People described seeing the registered manager regularly and felt they were approachable. One person told us, “I do know the managers and there is the owner too. They’re all approachable.” One relative told us, “The managers are approachable. The door is always open for a personal meeting.”

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard.

Staff described managers as accessible and felt encouraged to raise issues informally or formally. Staff felt confident their voices would be heard. One staff member described raising issues through written notes, which leaders responded to promptly.

Clear policies were in place for whistleblowing and complaints, which outlined escalation routes internally and externally. Staff were aware of these systems and understood how to raise concerns.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Employment practices supported equality and flexible working. Staff had access to equality and diversity training, and leaders demonstrated an awareness of protected characteristics and individual circumstances. One staff member told us how leaders supported them with a phased return to work following a period of absence. Managers encouraged staff development through qualifications and supported progression.

Leaders demonstrated an understanding of the diverse backgrounds, cultures and beliefs of staff. They took steps to support their individual needs. Staff told us leaders provided opportunities for them to observe important events and traditions where possible. For example, leaders supported staff who wished to fast during religious periods by making reasonable adjustments where appropriate.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these systems to monitor quality, manage risks and drive improvements They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were effective systems for assessing, monitoring and improving the service. Regular audits were completed across areas of the service, including medicines management, health and safety, infection control and staffing. Where improvements were identified, action plans were developed to ensure these were addressed.

The provider recognised that changes in staffing had affected the frequency of some supervisions. Leaders had identified this through their oversight processes and took action by training additional staff to undertake supervisions. The registered manager and senior staff remained available to support staff and support with informal supervisions during this time.

Leaders understood the risks affecting the service and took appropriate action to manage these. Risks were regularly reviewed through governance processes and lessons learnt from incidents. Leaders monitored staffing levels and recruitment needs to ensure people received safe and consistent care.

The provider submitted notifications to relevant external organisations as required, and leaders worked with healthcare professionals to support positive outcomes for people.

The provider worked in partnership with other services to help ensure people's care was coordinated and responsive to their needs. They shared information and learning with partners and collaborated for improvement.

Leaders maintained a close working relationship with healthcare professionals, such as GPs, who visited the service regularly to ensure people received coordinated care. This enabled people to access the support they needed in a timely manner. Referrals were made promptly when concerns were identified. Records showed effective communication between services to ensure continuity of care.

The provider worked with people and those important to them. Relatives told us they felt informed and records reflected ongoing communication regarding changes in people’s needs.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. However, systems were not always effective in identifying and addressing all areas requiring improvement.

During the assessment, we identified gaps in care plans in relation to protocols for supporting people experiencing seizures and recording the potential side effects associated with prescribed medicines. We also found thickening agents stored in people’s rooms. The potential risks associated with unrestricted access had not been formally considered or mitigated. Whilst there was no evidence people had been harmed, the provider had not identified these issues. We discussed this with the provider, who acknowledged the concerns and agreed to review the storage of thickening agents and care plans.

Staff were encouraged to reflect on practice and contribute ideas to improve the service. Team meetings and supervisions provided opportunities for learning. Staff told us they felt listened to and were confident in raising suggestions and opportunities for improvement with management.

Leaders demonstrated a commitment to learning from incidents and feedback. Lessons learned were shared with staff and included within people’s care plans and risk assessments. Leaders continued to attend training events and conferences covering health and social care topics, such as diabetes management. This enabled them to remain informed about changes in legislation and best practice guidance. This knowledge was used to review care plans and working practices to help people receive care and support that promoted positive outcomes.