Brandon Trust - 261 Passage Road 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 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 75 (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.

All staff we spoke with were very committed to providing care that was person centred and very much led by the person and their interests. Feedback from relatives was positive about the staff team and how they worked together to support the individuals in the home.

Observations of how staff interacted with each other and the management of the service showed there was a positive culture with staff having mutual respect for each other. Staff were clear about their roles and responsibilities as well as the organisational structure and who they would go to for support if needed.

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 manager was responsible for another service and split their working week between the two services. Staff confirmed the registered manager visited the service at least twice a week and telephoned on a daily basis to provide support. The registered manager was supported by a team leader who worked solely in 261 Passage Road.

The provider’s representatives regularly visited the service to check on the quality of the service. Staff told us, the chief executive had also visited the service and sang Christmas carols with the people who lived in the home. Staff said this had been very much enjoyed by everyone.

The provider supported people with learning disabilities by establishing a group called The Adventures. Members of this group were actively involved in reviewing and checking the quality of the services operated by the provider, Brandon Trust. This demonstrated the provider’s commitment to inclusion, as people using the service were given a meaningful voice in how it was delivered and improved.

The registered manager attended monthly management meetings where learning and risks were discussed across the whole organisation.

The registered manager and the team leader were clear about their responsibilities for reporting to the CQC and the regulatory requirements of managing a care home.

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

Staff felt able to speak up and were confident their concerns would be heard and addressed. They said they would not hesitate to raise issues with the management team or provider.

The service had policies, including a speak up (whistleblowing) policy. Staff knew how to escalate concerns internally and externally, including to the local authority, CQC or police if needed.

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.

People were supported by a staff team who felt valued and supported in their roles, with staff reporting they enjoyed working at the home. They received appropriate training, enabling them to feel confident and skilled in supporting people, and their views were sought through team meetings and supervisions.

Policies were in place to promote and protect the rights of both people using the service and staff, and staff had completed equality and diversity training.

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

The registered manager and team leader carried out regular checks on the home and people’s experiences, covering care, medicines, the environment, health and safety, and staffing. Where improvements were identified, action plans were put in place.

The organisation’s quality team also completed regular audits aligned to the CQC key questions of safe, effective, caring, responsive and well-led.

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.

People were encouraged to maintain relationships with those who were important to them and engage in activities, which were meaningful and improved their quality of life. People confirmed they were supported to go out within their local community on a regular basis. Staff worked alongside a day care provider to ensure care was joined up. Relatives told us they were very much involved and asked their views about the care and support provided. A relative told us, “You are always made to feel welcome and that is all down to the wonderful staff and management”.

The registered manager and staff team worked with a range of healthcare professionals, including GPs, occupational therapists, dentists and chiropodists, to ensure people’s health needs were met and reviewed. People were supported to attend hospital appointments and health care reviews when required. A health professional told us, “My communication with the staff at 261 Passage Road was consistently positive and efficient”.

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.

There was a culture of learning and improvement at the service. Staff told us they were continually reviewing the care and support ensuring it was meeting the needs of people and whether there were ways improve their quality of life and their independence. A member of staff told us, “As a team we are always striving to improve the care we provide, and I amvery proudto be part of a team like this”.Another member of staff told us, “261 Passage Road is an environmentwherewe all feelwe can raise questions and concerns and we will find a solution together”.

Annual surveys were collated from people and their relatives. These were completed by the provider, and any themes were explored across the organisation to drive improvements.

Staff members said they were encouraged to undertake continuous training to enable them to provide safe and effective care. This was constantly kept under review.