Stanley House

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 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 service was in breach of legal regulation in relation to governance at the service.

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 provider 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 provider was focused on making improvements to people’s experiences of care whilst maintaining the, ‘family-home’ feeling of Stanley House. They had introduced digital care planning and record systems and whilst they acknowledged there were some issues involved in rolling this out, they told us they were determined to address them. Environmental improvements were underway, including improvements to medicines storage areas and the renovation of people’s bedrooms. The provider told us they highly valued their staff group and involved them in how improvements could be made and sustained.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They worked with integrity, openness and honesty. However, Leaders had not yet embedded the skills, knowledge, experience and credibility to lead effectively.

Leaders told us there were still issues with the accuracy of people’s care records due to the staffs’ knowledge and use of the new digital care planning system. Whilst Leaders were working with staff to improve the use of the system, this had not yet been effective. They had not as yet developed a range of effective audits, checks and investigations that would reliably identify where improvements to the electronic care planning system as well as in the wider provision of care were required. Leaders’ knowledge on when to notify the Care Quality Commission (CQC) needed to improve.

However, Leaders told us staff could approach them at any time and staff described leaders at the service as supportive. During our assessment, leaders worked as a team to support the inspection process. Leaders’ contributions to our assessment process were open and honest and they demonstrated their integrity by acknowledging when things could improve.

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

Staff understood the process to follow if they needed to ‘whistle-blow.’ Whistleblowing is a law that protects staff from being treated unfairly by their employer if they have raised genuine concerns about a person’s care. The provider told us they visited Stanley House regularly and staff could contact them direct. Staff were confident that the leaders at the service would act on any concerns raised. One staff member told us, “I think it is really good here, I wouldn't have stayed this long if it wasn’t. There is no-one you cannot go and talk to, I am quite outspoken, I don’t feel I can’t speak out here.”

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.

The provider told us they valued the staff teams working at Stanley House and their approach had been to involve and listen to staff when planning improvements at the service. Staff told us they felt treated fairly and were supported by leaders at the service.

The provider did not have suitably clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s systems and processes to assess and monitor the quality and safety of services and to identify and embed improvements were not operated effectively. For example, we found shortfalls in people’s care records, care planning, incident investigation and risk mitigation, not all of which had been identified by the provider’s own checks prior to our inspection.

The provider’s systems had not checked to ensure all required statutory notifications had been submitted to the CQC as required and that staff received their required training in health and safety. Whilst the provider had produced a newly written data impact assessment (which is required for the operation of the CCTV system), in response to our request to see one, they were unable to locate the original document which meant the provider could not demonstrate it had been kept under review. They had not displayed the required notices to advise people, visitors and staff CCTV was operated on the premises. Systems had also not ensured people’s consent for being recorded on CCTV had been considered.

The provider 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.

Leaders told us there was a weekly ward round where a healthcare professionals from the local GP practice attended and reviewed people’s needs, along with a monthly ward round with the visiting GP. We observed visiting healthcare professionals attending to people’s healthcare needs on the day of our inspection. Where people had involvement from other healthcare professionals, this was included in their care plans. This helped to ensure partnership working with other agencies contributed to people’s care outcomes.

The provider was working towards continuous learning, innovation and improvement across the organisation and local system. However, the systems to support this were not yet fully effective or embedded.

The registered manager was working to make improvements by auditing aspects of people’s care and identifying where improvements were needed. These were communicated to the staff teams and during meetings to reflect on lessons learned. A recent staff briefing had focussed on falls prevention, with ongoing monitoring of falls in the home to look for any patterns or trends and how to mitigate those. However, we found that these actions had not yet been fully effective at ensuring all necessary improvements or embedding consistent good practice.