Sotwell Hill 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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service remained in breach of legal regulation in relation to governance and were further in breach of failing to notify the commission of notifiable incidents.

This service scored 64 (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 demonstrated a clear and shared vision, strategy and culture that was embedded within the service. This was based on principles of transparency, equity, equality, diversity and inclusion, and a strong understanding of the needs of people and the communities they supported.

Leaders and staff demonstrated a positive, compassionate and inclusive culture. There was an emphasis on listening to people and learning from feedback, which helped to build trusting and respectful relationships between staff and people using the service.

People spoke highly of the service and the management team. One person told us, “They look after us so well, it is very well managed. People [carers] have been here a long time.” This reflected a stable workforce and consistent leadership, which supported continuity of care and strong relationships.

The culture within the service promoted openness and understanding. Staff were encouraged to listen to people, act on their feedback and work collaboratively to improve outcomes.

The provider demonstrated inclusive leadership at all levels. Leaders understood the context in which care, treatment and support were delivered and consistently. However, there was a lack of improvements implemented following the last inspection findings.

Although leaders promoted a culture where people felt listened to, valued and respected, within the service, this was not consistently supported by effective systems and sustained improvements. Their presence helped to encourage open communication, and people felt able to raise concerns and discuss their care. However, issues identified at the previous inspection had not been sufficiently resolved. There has been limited progress in ensuing documentation was consistently accurate and up to date, and improvements had not been fully embedded into practice.

Leaders were present within the service and took time to build meaningful relationships with people. People spoke positively about the leadership team and described them as visible and approachable. One person told us, “Staff definitely make time to talk to me [manager] is particularly good to talk to.” Others said, “I do know the owners and the manager. They come along and talk to me nearly every day. I know I can talk to them at any time if I needed to,” and “I see the owners quite often, nothing is too much trouble for them.”

Staff told us they felt well supported by the leadership team and were able to ask questions when needed and worked well as a team. This created a positive working environment where staff felt confident in their roles and able to deliver person‑centred care.

The provider fostered a positive and open culture where people and staff felt able to speak up and have their voices heard.

Staff told us they were kept informed and involved following incidents, with opportunities to reflect and learn from events. They demonstrated a good understanding of how to raise whistleblowing concerns and said they felt confident to do so if needed.

Staff felt able to approach managers and raise concerns openly. They described managers as approachable and supportive, which encouraged an environment of openness and transparency.

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.

Leaders took action to address any disparities in staff experience and worked to ensure equitable opportunities for development. Staff told us they felt supported within their roles and were given opportunities to learn and progress.

We heard examples of staff being supported to develop their skills and confidence through additional opportunities and encouragement from leaders. The provider was committed to investing in their workforce and promoting an inclusive environment where staff could grow and succeed.

The provider did not always have clear responsibilities, roles, systems of accountability or effective governance. They did not always accurately document information relating to risk, performance or outcomes, nor did they consistently share information appropriately to support safe and effective care.

Governance systems were not always effective in identifying or addressing known issues.

Oversight of staff training was not always robust. The training matrix did not consistently evidence all staff had completed the required training to carry out their roles. While staff demonstrated knowledge in practice, records did not provide full assurance training had been consistently achieved. Leaders were not always recorded as competent within the matrix. The provider told us this was a documentation oversight; however, gaps in records limited effective oversight.

Safeguarding processes were not consistently followed. Safeguarding concerns had been identified by the service, and action was taken to support people’s immediate safety. However, these concerns were not always referred to the appropriate safeguarding authority, and the Care Quality Commission (CQC) had not always been notified as required. This reduced external oversight and assurance safeguarding processes were being followed in line with regulatory expectations.

Risk management systems were not consistently effective. Where risk assessments were in place, they did not always provide sufficient detail to guide staff on how to respond and mitigate risks. For example, risk assessments relating to diabetes management identified signs and symptoms but did not clearly outline actions staff should take or how to recognise and respond to changes in people’s condition. While the registered manager was able to describe appropriate responses, this guidance was not consistently documented for staff to follow.

We identified inconsistencies within care planning documentation. Although some care plans had recently been updated, records did not always align with current practice, indicating weaknesses in audit and review processes. Risks previously identified at the last inspection, such as the absence of risk assessments where risks were known, had not been consistently addressed. Improvements had not been fully embedded or sustained.

Medicines management systems required improvement. Where people were supported to self‑administer medicines, there was not always clear information about the purpose of the medicines or associated risks. Records relating to the return of medicines were not always accurately maintained and had not been identified through audit processes. In addition, care planning documentation did not always reflect the correct medicines management arrangements.

Guidance for staff to manage health risks was not always clearly recorded. Although staff were able to describe appropriate actions, this was not consistently documented, which reduced assurance all staff had access to clear guidance.

Staff recruitment records did not include interview questions. The provider has since introduced a revised recruitment pack to address this.

Environmental risks were not always effectively identified or managed. For example, people with known falls risks could access staircases. Although some control measures were in place, risks associated with access points, such as unsecured doors, had not been fully assessed.

Audit systems were in place, and some documentation showed areas for improvement had been identified. However, the provider was not always able to demonstrate actions from audits had been completed or effectively followed up. This limited assurance governance systems were being used to drive improvement.

The provider demonstrated a commitment to continuous learning and improvement, and there were systems in place to review incidents and identify learning. The service encouraged approaches to improve people’s experiences, including promoting equality and quality of life. However, improvements were not always consistently implemented in practice.

Written guidance did not always support staff to manage risks consistently. At the previous inspection, improvements were identified in relation to risk assessments. While staff demonstrated a good understanding of people’s individual risks and needs, documentation had not been fully updated to reflect this.

Lessons learned from incidents, including falls, were reviewed and analysed. Systems were in place to monitor incidents and identify trends. However, where risk assessments had been completed, they did not always include sufficient detail to guide staff on how to respond and mitigate the identified risks. This reduced assurance that learning from incidents was fully embedded into practice.

The provider demonstrated a commitment to continuous learning and improvement, and there were systems in place to review incidents and identify learning. The service encouraged approaches to improve people’s experiences, including promoting equality and quality of life. However, improvements were not always consistently implemented in practice.

Written guidance did not always support staff to manage risks consistently. At the previous inspection, improvements were identified in relation to risk assessments. While staff demonstrated a good understanding of people’s individual risks and needs, documentation had not been fully updated to reflect this.

Lessons learned from incidents, including falls, were reviewed and analysed. Systems were in place to monitor incidents and identify trends. However, where risk assessments had been completed, they did not always include sufficient detail to guide staff on how to respond and mitigate the identified risks. This reduced assurance that learning from incidents was fully embedded into practice.