Estervin Court Residential 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.

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of 1 legal regulation in relation to good governance at the service.

This service scored 43 (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 did not have a shared vision, strategy and culture based on transparency,

equity, equality and human rights, diversity and inclusion, and engagement. They did not

understand the challenges and the needs of people and their communities.

The provider told us they were striving for excellence however the leadership structure did not support this. Staff did not always have the knowledge, skills, and experience to know what excellent care looked like.

The management team was not always visible or available to support the staff to understand their vision.

Staff we spoke with were not confident in recognising what a closed culture looked like but told us if they saw poor practice they felt comfortable to report it and felt confident it would be acted on by management. People told us staff were ‘nice’ and ‘caring’.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Not all of the leadership team had the knowledge, skills, and capability to carry out their role safely.

We found a lack of quality assurance checks taking place on tasks completed outside of personal care. For example, there were cleaning schedules completed by care staff and signed off by the shift manager but as we were walking around the building we could see some of these tasks had not been completed for longer periods of time. We saw maintenance checks were not being completed properly for 10 months, which increased the risk of harm to people using the service.

People did not always feel they could speak up and that their voice would be heard.

The provider did not always complete staff supervisions. Completed staff supervisions were not always completed within the provider’s own policies. Some staff did not have completed annual appraisals in their staff folder.

The provider did not always hold regular team meetings, and no minutes were available for team meetings for the last 12 months. This minimised the chances of people’s views and opinions being given, potential areas of improvement being overlooked and areas of poor practice not acted on. There was no action plan or learning points taken from staff meetings.

Staff told us they could raise concerns with the registered manager at any time and felt confident to do so. Some staff understood what whistleblowing meant and that they felt comfortable to do so if required.

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. Staff we spoke with told us they were treated fairly at work and were supported within their role and when personal circumstances were affecting their wellbeing.

Staff said they were happy working for the provider, and in some cases had been there for over a year.

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

The provider did not have effective processes or systems in place for the monitoring of the quality of care provided to drive improvements. The provider failed to operate robust quality assurance systems and processes to support the registered manager in identifying the on-going concerns we found. For example, we found inaccurate and unclear information in people's care plans. That meant opportunities to drive forward improvements to benefit people had been missed.

The provider failed to carry out robust staff recruitment checks to identify discrepancies in staff records which was unsafe. There was missing information in staff files. In addition, systems to assess the effectiveness of staff training were not robust in making sure staff were competent to carry out their roles. This lack of oversight meant the provider could not assure themselves their staff were skilled and had the necessary knowledge to undertake their job roles.

The provider had failed to ensure their safeguarding processes to identify when people were at risks of abuse were robust. During this inspection we raised several safeguarding alerts to the local safeguarding team as we found people were at risk from harm.

The provider had failed to follow their own policies and procedures. This meant they were not always meeting the requirements of current legislation.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Staff told us they could make referrals to health and social care professionals via the management or team leader, and team leaders confirmed this. They were able to explain this process to me, but the information was only stored on the shift handover sheets. This information should be recorded in the person’s file so it is easily accessible for reference, and auditable.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not always actively contribute to safe and effective practice. areas for improvement had not been identified through management checks or audits. There were no processes in place to review and analyses accidents, incidents or safeguarding’s in order for learning and improvements to be made at the service.