Casa Mia Care Home

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 changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider and staff told us the service values were promoting dignity and respect and ensuring people achieve their goals and aspirations. The registered manager said, “We treat people like friends not clients, we want to ensure people live a fulfilled life, and we lead by example. My ethos around working with staff you have, is helping them improve their skills, this has provided continuity of care which is so important for the wellbeing of our people. And as we work today to help people get back into the community building their confidence and self-esteem. Continuity of care is key”.

The service instructed external mock inspections to monitor and manage compliance; this was also used to look at areas for improvement and monitor staff wellbeing. The most recent inspection highlighted some staff had low morale. The registered manager took prompt action to address this to ensure staff were heard and able to voice any concerns. The provider held an offsite team meeting and devised a power point presentation with all staff to discuss the findings, listen to their concerns and work together to alleviate some of the issues. The provider took time during the session to formally acknowledge and thank the team for their hard work and commitment to Casa Mia Care Home. Following this, the registered manager completed supervisions with each staff member, focusing on their wellbeing. Staff reported some of the contributing factors relating to low morale were not having enough time to complete online training and the introduction of new IT systems. The registered manager made changes to the training time allocated to all staff, so everyone would have enough allocated time to complete their requirements. This resulted in improved compliance of 97% and improved staff morale. A staff member told us, “Staff morale was really low, but it was due to introduction of new IT systems. It was a case of sitting down and explaining the importance of why we do it, why carers have extra responsibilities. Once the staff understand they take it onboard and it’s much better now”.

The provider had exceptionally 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 always did so with integrity, openness and honesty.

Leaders of the service were highly experienced and had worked at the service for many years. They were approachable and demonstrated exceptional knowledgeable of people’s support needs. The provider, registered manager and leaders were consistently praised by people, relatives and external professionals. A person told us, “The management are good. They talk to me about my care. There’s nothing that could be better here. Everything here makes me feel good”. A relative told us, “Staff are really happy when [registered manager] is here, they are always smiling, always happy. Nothing to improve”. Staff shared the same views of leaders, a staff member told us, “Management are lovely, [deputy manager] is lovely, they are amazing. If an emergency day off was needed, they sort it with no worries”. Leaders maintained a visible and supportive presence throughout the service and staff spoke of a positive rapport with the leadership team. The provider told us, “We are immensely proud of getting Casa Mia to what it is today, this is my overall greatest achievement”.

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

People had the opportunity to raise any concerns in regular meetings which were chaired by a person living at the service. Relatives told us they knew how to raise a concern and were assured, if needed any actions would be taken. Two relatives told us they had shared concerns about their loved one’s accessibility when they were allocated rooms on the first floor. Both relatives told us leaders took action and relocated people to ground floors rooms without delay.

The provider had an ‘open door policy’ which meant people, staff and families could approach them at any time if they had any concerns. The registered manager understood their responsibilities under the duty of candour. The duty of candour is to be open and transparent, and it sets out specific guideline's providers must follow if things go wrong with care and treatment. The provider told us, “We promote a robust ‘Freedom to Speak Up’ culture, ensuring all staff feel confident to report concerns without fear of blame”.

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 service promoted an inclusive and fair culture and had an equality and diversity policy in place to guide equitable and fair recruitment and selection procedures. The provider’s recruitment policies and procedures helped ensure staff experienced equitable treatment.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

This was the third inspection where the service produced multiple examples of going above and beyond to monitor and improve the safety and quality of people’s care. Leaders maintained a robust governance framework, utilising monthly audits, reviews, and monitoring tools to guide better outcomes for people. Data from monitoring and reviews enabled the leadership team to maintain robust quality control while driving continuous service development. Furthermore, the provider adhered to quality tools and best practices by sharing regular policy updates in staff bulletins and meetings and maintaining a comprehensive business continuity plan for emergency preparedness and any adverse events. Additionally, the provider commissioned external independent mock inspections to review the services overall performance, this enabled the provider and leaders to drive learning, share best practices, and implement changes which enhanced the safety, health, and welfare of people. This proactive approach facilitated continuous evolution, ensuring a responsive service which delivered high-quality, person-centred care.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The service had a systematic approach to working with other organisations to improve care outcomes. The providers and staff championed the rights for people with mental health. This included involving local community, shops and pubs to remove stigmas and pre-conceived ideas about mental health. This now meant they were willing to work with Casa Mia Care Home and support people in the community. The providers and leaders were active members of the Worcestershire Care Association (WMCA) and attended care shows to keep abreast of some of the latest innovations in the care sector and updates to improve the quality of care provided.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Sharing learning through team meetings, daily handovers, and supervisions encouraged staff to reflect on their practice and develop skills. This established a supportive culture where staff felt confident to learn and continuously improve.

Where staff had shared some barriers to their workload, leaders had taken action. One of the these included spending time completing administrative tasks, the provider employed an additional administrative assistant to work offsite. The provider shared, through operational review, they had identified opportunities to centralise non-clinical administrative tasks and better utilise specialist administrative support. A successful example of this which had already been implemented was the daily backup and management of MAR chart documentation, this had reduced workload for team leaders. Leaders had identified their new digital care system did not meet the current organisational requirements, and specific information about people could be difficult to locate and did not always link to similar themes. The provider was in the process of migrating to a new digital provider which better suited the service. The provider, leaders and staff were passionate about continuing to improve the service, and further plans were detailed in the providers service improvement plan.