The Four Seasons Trust Limited - 33 Abbotswood

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 service 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 clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an understanding of the challenges and the needs of people and their communities.

The registered manager told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. Staff told us there was a good and positive culture within the home where people and staff had a good rapport, and the atmosphere was one of respect and care. There were no staff meetings organised at the service. The registered manager told us these had been replaced by a WhatsApp group whereby information, ideas and suggestions were discussed.

There were meetings with the trustees 3 times a year. The registered manager told us, “We discuss everything. A chance for me and the deputy to meet the trustees and discuss what is going right or wrong. Like choosing a builder to do the building work, etc.”

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

The management team were committed to developing the service for the benefit of people who used it. The registered manager told us, “We plan to have the whole building renovated. We are now moving to the residents’ bedrooms. This is discussed with the people and their families. Parents are heavily involved. You could describe us as a big happy family.”

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 provider, The Four Seasons Trust, is a non-profit organisation led by a team of trustees. The registered manager told us they had a good working relationship with them.

People knew who the registered manager was and told us they had a good relationship with them and the rest of the staff. Relatives stated, “We regularly collect [Family member] for home visits and often see the manager in person, where we have informal and helpful conversations”, “I find the manager is excellent and sets a high standard, which [their] staff follow” and “I have total confidence that the manager and trustees are always vigilant to the care [Family member] is receiving.”

All the staff we spoke with were positive about the registered manager and provider. They told us the service was good and the managers valued and respected them.

The registered manager described themselves as ‘one of the staff’. They told us they cared about people and the staff and wanted to run a happy place for all. They used to be a care worker and had worked their way up to registered manager. They told us, “I have got level 5 in health and social care. I have signed up myself and the staff to the learning development support scheme. This is a government initiative where you can claim back funding. They have a range of training, so whatever I think I need brushing up on or the staff, we can access this.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People and relatives were given information when they moved to the home about how to raise a concern, and said they knew how to make a complaint.

The registered manager told us they took complaints seriously and always ensured they took appropriate action to investigate and respond to people. However, there was no record kept of the complaints received, and what action had been taken. This meant we could not be sure the provider took appropriate action, and there was a concern they could not analyse any trends or themes so they could make improvements.

People were supported to share their feedback about the service via regular meetings. The registered manager told us they usually send out quality questionnaires to people and relatives, but they had not issued this yet and were waiting for the renovations to be completed.

The provider had some processes in place to support staff to speak up. This included supervision meetings, staff meetings and a whistleblowing policy. Staff demonstrated an understanding of their responsibility to speak up.

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 had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. Staff were supported to develop their skills within the company. Staff’s needs were reviewed and reasonable adjustments made as necessary. Staff’s cultural and religious needs were supported.

The provider did not always have clear responsibilities, roles, systems of accountability and 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 had monitoring systems in place. However, these had not always been effective and had failed to identify and address the concerns we found during our inspection. Checks and audits were not always regular or recorded, therefore we could not be sure they took place as required. For example, infection prevention and control and environmental audits.

The provider did not always ensure concerns about safety were investigated and addressed in a timely manner. Lessons were not always learnt to continually identify and embed good practice.

For example, although incidents and accidents were recorded, the provider had not ensured these records included an analysis or review of the incident to determine any underlying causes or trends and to identify any actions and any learning outcomes.

Processes to help ensure that risks to people were assessed and mitigated were not always effective. Although some risk assessments were comprehensive, others lacked detail and did not provide robust information about individual risks and how to mitigate these. This meant there was a risk staff would not be able to protect the person from avoidable harm.

Record keeping was disorganised and difficult to navigate. The registered manager was not always able to find documents we requested in a timely manner, for example, it took 3 days for them to send us a requested risk assessment. The provider kept records both electronically and in paper form and did not always know where to find information and documents. This meant we could not be assured records were reviewed were updated as needed, and staff could not access these as needed. The registered manager told us, “I know there are things we are good at and others we need to improve on. Like learning. When something goes wrong, what did we learn or rectify. I need to make sure I regularly talk to staff and take action. I would not say I am laid back but things are always changing and I need to keep on top of things.”

Although the registered manager told us staff received training, the training matrix they showed us indicated most staff had not received training in a range of subjects, or these had not been refreshed. Despite repeated requests for further evidence, we did not receive it. This meant there was a risk that staff did not receive required training, or the registered manager lacked oversight of staff training needs.

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.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals. For example, the GP and the local authority.

The provider had systems and processes to ensure people’s needs were reviewed with external professionals.

The registered manager told us they ensured the staff learned from healthcare professionals involved in people’s care to help them better understand people’s needs. Our conversations with various support staff showed they understood people’s needs and were keen to learn from professional input.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

People told us they were consulted individually during a review or regular conversation to find out if they had any concerns or requests. They also had the opportunity to participate in the running of the service during meetings. We saw that people’s opinions and requests were taken seriously.

Staff told us the registered manager was always aiming to make improvements to the service in order to benefit people, and they enjoyed being part of this. Work had been completed to install a new kitchen, which people told us they liked.

The registered manager was committed to developing the service to benefit people and the staff team. Following concerns raised by a relative about their family member’s bedroom, this had been renovated and re-decorated. The person was proud to show us their room.