Archived: The S.T.A.R. Foundation

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 requires improvement. At this assessment the rating has remained 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 legal regulation in relation to governance at the service.

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.

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 registered manager was committed to ensuring the provider values were delivered and supported staff to do the same. Staff felt valued and people felt included.

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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. The registered manager understood their responsibilities and legal requirements. People and relatives felt the home was managed effectively and staff felt supported by the management team.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy and fostered an open and transparent culture where employees felt empowered to raise genuine concerns regarding malpractice within the organisation. This whistleblowing policy outlined the procedure for reporting concerns, protecting employees from retaliation, and ensuring all concerns are addressed appropriately.

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. There was an inclusive and fair culture with equality and equity for staff. All staff were positive about working at The S.T.A.R Foundation and said they were treated with respect.

The registered manager had good oversight of the service, however, the recording of this required improvement. Staff and the registered manager could tell us additional checks were taking place to ensure the care provided was to a good standard, however this was not always recorded. For example, additional spot checks were taking place throughout the day to ensure cleanliness and peoples safety but there were no records of this. Governance systems in the service needed improvement. We found that not all governance audits which were in place at the time of the inspection were effective in providing oversight of all care areas. People’s care plans were not detailed or accurate and while staff knew people well to keep them safe, not all risks to people had been recorded. For example, people who were at risk of developing skin issues did not have appropriate skin monitoring in place. The registered manager set out developing action plans for these areas following our inspection.

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. The management team expressed an open positive attitude to receiving support and understood how and where they could access support, to ensure continuous improvement to the service. The provider fostered good working relationships with partners and communities.

The provider encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.The provider had made investments into the service to help innovate and improve. For example, environmental improvements had taken place and new fire doors had been fitted throughout. A rolling programme of refurbishment was underway to drive further improvement.