Mrs P M Eales t/a Just Homes - 3 New Hill

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.

The service was in breach of legal regulation in relation to good governance. Some care records were not comprehensive or up to date and the provider’s monitoring systems had not identified this shortfall.
 

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 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. Staff told us they “Gave care through relationships based on empathy, care and dignity” and “The visions and values were person centred.” Throughout our assessment we saw people receiving care in accordance with these values. We reviewed the provider’s statement of purpose which clearly set out their values. We saw a culture of teamwork and staff had time to engage with people and professionals. The provider had a service user guide which clearly outlined what people can expect from them.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, Staff told us they had staff meetings. Staff told us management were available whenever needed and they encouraged themselves and staff to deliver the best standards of care. Relatives told us the home was well-managed and they “Agree with the number of staff and carers present.” However, we found some development was needed to ensure leaders would always operate the provider’s governance systems effectively.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider gave staff the opportunity during supervision meetings to share any feedback or concerns they might have about the care people received. Staff told us they were aware of freedom to speak up, they knew they could raise concerns and feel safe and confident in doing so. Staff told us any issues or concerns were acted upon, staff communicated with each other and described a positive work culture. Staff told us, “I feel well supported in my role and have often spoken up and I feel my opinion has been respected and valued” and “We have an open-door policy in the home that the staff know they can chat to the management.”
The provider had a whistleblowing policy which outlined the policy and procedure to support the provider's commitment to a culture where speaking up was valued and protected. The provider told us they had "Ensured that the whistle blowing protocol is displayed should anyone want to make a complaint."
 

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 were no concerns received about lack of diversity or inclusion for members of staff. Staff told us they did not have any concerns about the way the service treated them. Comments included, “No concerns” and “I have not had any concerns about how I’m treated.”

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

The provider’s quality and risk monitoring systems had not always been effective in identifying shortfalls that could impact on people’s care. For example, they had not identified the shortfalls we found in relation to medicine records. Systems in place had not ensure all care plans including in relation to people’s epilepsy, asthma and diabetes, were reviewed in accordance with the provider’s requirements. People’s DoLS arrangements had not been monitored to ensure when these expired prompt action would be taken to inform next steps. The provider started taking action during the assessment to address these concerns.

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. A professional told us, "The service maintains good communication and provides timely responses to any requests made" and from their latest review of the service, they "Did not identify any concerns in relation to the leadership or management of the service." Another professional told us, "The registered manager has always been contactable and responsive to our input and when we have been coordinating care for our patients who live there."

The provider strove to focus on continuous learning and improvement across the organisation and local system. The provider held staff meetings and acted on feedback received from relatives to make improvements to the home. However, the provider did not always operate effective quality monitoring systems which meant they might not always identify and act on the areas that required improvement and development.