Safeharbour (254 Hagley Road)

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 68 (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. The provider’s organisational values were in alignment with CQC’s ‘Right support, right care, right culture’ guidance.

Staff and the management team worked with people and their representatives to build a culture that focused on enabling people to enjoy their lives.

Staff were aware of the values of the organisation and spoke positively about the culture of the service. Discussions with staff demonstrated their awareness of closed cultures, and how these could develop and the action they would take. A staff member told us, “My role is to ensure people have a good quality of life and if I had any concerns that someone was preventing this, or not working in accordance with peoples care plan. Or if they were being disrespectful to people, I would report this straight away.” The registered manager told us they regularly worked on shift alongside staff to monitor care practices.

Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff and relatives spoke positively about the management team. A relative told us, “The manager is approachable and manages the service well. I have confidence in their ability. I think it is a good home, and [person] is well cared for.”

Staff told us the registered manager was supportive and felt confident they would be listened to if they had any concerns. A member of staff told us, “The manager is lovely and supportive and has time for staff, I feel I can go to her with any issues.”

The management team were visible within the service and led by example to their staff team, demonstrating inclusive behaviours. Staff knew their roles, responsibilities and how to support each other.

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

Relatives felt confident to raise and share concerns. They were confident action would be taken. A relative said, “I know I can share any concerns or issues with the manager or staff they listen and take action.”

The provider had a whistle blowing policy and procedure in place. Whistleblowing is the term used when staff share information of concern. There was a culture where staff felt safe and confident to raise concerns without fear of reprisal.

Staff were aware of their responsibilities to report concerns and were able to describe the action they would take if they witnessed or suspected any abusive or neglectful practice. A member of staff told us, “If I have any concerns, I will go straight to the team leader or manager. If they didn’t take any action, I will go to external agencies such as the local authority or CQC.” Staff had received training and were aware on how to escalate any concerns they might have to external agencies. We also saw this topic was discussed during staff meetings and supervisions.

The provider had systems in place to gather feedback from staff including completing surveys. This enabled staff to share any concerns confidentially if they did not have the confidence to use other methods in place. The registered manager told us they had created an open-door policy where staff were able to speak up and share their concerns at any time.

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 registered manager ensured people and staff had an equal opportunity and were not treated differently or discriminated against and valued individual differences. People and staff had equal opportunity to fulfil their potential. Staff told us they felt valued, respected, and included. There were regular meetings held with staff to share their views and experiences and for the registered manager to cascade information about things happening in the service. The provider also gained feedback from staff as part of quarterly audits that were undertaken to ensure staff’s voice was heard about the way the service was managed.

Systems were in place to maintain oversight of the service. However, some improvements were required to ensure records reflected this oversight and included all the required information.

Although systems were in place to monitor the quality of the service some improvements were required to make these more robust. For example, it was not clear from the incident records if the registered manager had signed these off to ensure they had been completed to the required standard and contained the required information. It was also unclear what actions may have been required from this review as records were not in place to reflect this. We saw these records had been reviewed as part of the provider’s quarterly audit with actions for the registered manager to implement. The management team was receptive to our feedback and told us they would be implementing weekly audits to review these records so timely actions could be made to address shortfalls.

We found the quality and detail of some records were not always consistent across the service, for example daily records to ensure they reflected people’s wellbeing and were not task focused. We also found in some records the language used was not always positive. Some care plans did not always contain person centred information. We also found information shared with families was not always recorded and inventories of people’s belongings were not always kept up to date. Audits of care plan and records did form part of the manager and provider’s audit, and actions were in place to improve the standards. Training had also been planned for staff in relation to report writing.

Weekly and monthly audits were completed by the staff and the registered manager to cover other aspects of the service. For example, medicines, finances, and the environment. Where shortfalls were identified, appropriate actions were taken to resolve them.

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 worked closely with a number of health and social care professionals, and this helped to ensure people’s needs were met. People had the contact details of their doctor and other professionals recorded within their hospital and health action plans.

Staff monitored people's health and welfare and any emotional distress. This information was shared with healthcare professionals to support any changes to people’s support plans. Staff knew what actions they needed to take if a person became unwell. The management team made referrals to health care professionals where required.

Staff worked with advocates, who told us staff listened and acted upon any recommendations. Feedback received from partner agencies was positive. Agencies confirmed the provider worked with them and completed any recommended actions following quality visits.

Although the provider had systems to focus on continuous learning, innovation and improvement across the organisation some improvements were required to make these more effective.

The provider had systems in place to learn lessons and drive improvements, however some of these needed improving further. For example, incident analysis was taking place every 6 months in preparation for people’s reviews. However, there were some missed opportunities to include additional information such as staffing, and sleep patterns. The data was not always analysed further and explored for patterns and trends, to learn lessons and reduce further incidents. A summary of the data was not always provided and there was no comparison every 6 months or year on year to see people’s progression. There was detail about what may have caused distress for people and what had been tried to alleviate people’s anxiety and distress. The management team was receptive to our feedback and demonstrated their commitment to making the required improvements.

The provider sent satisfaction surveys to staff and people’s representatives to gain their views and feedback about the service. Relatives commented positively when we gained their feedback about the care and support given to their loved one. A relative told us, “I am happy with the care [person] receives. The staff are great with [person] and the staff are very caring.” We saw there was also an anonymous suggestion box displayed where anyone could use the QR code to share their feedback. Any suggestions were taken on board and acted upon.

The management team kept themselves up to date with best practice in relation to health and social care. The provider had other services, and the registered managers met on a regular basis to share ideas on how they could improve their services further.