Divine Care Centre

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 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 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.

Staff spoke positively about the support they received from senior staff and management. They told us leaders were approachable and available to provide guidance and support when needed, which helped them feel supported in their roles.

Leaders promoted a culture where staff felt able to raise concerns and seek support. An open-door approach encouraged communication and discussion within the team. There was a shared understanding of how care should be delivered, and staff demonstrated a commitment to providing person-centred care.

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 newly registered manager told us they were passionate about empowering staff to advance their skills, something staff told us they valued. A staff member commented, “[Registered manager] has been supporting us to improve our care planning skills and I’ve really appreciated the advice.”

Feedback about the leadership of the home from staff, people and relatives was all positive. A relative told us, "It must be good management because the staff are happy and it lifts the mood completely. You can’t come in here and feel down.” A member of staff said, “Our Manager has not been in place very long and already I can see the positive effect they are having in the Care Centre. They always make time for everyone whether that be our residents, residents’ family friends, staff and visiting professionals. Their door is always open.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff we spoke with were happy in their roles and felt well supported. They had no concerns regarding the recent change in management and felt able to approach the registered manager with anything they needed to raise. A member of staff told us, “If concerns are raised, management take it seriously, and staff feel listened to. Suggestions and feedback are welcomed, and appropriate action is taken when 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.

Leaders considered individual circumstances and worked with staff to support different working arrangements where possible, including flexible hours and adjusted shifts. This approach supported staff to remain in their roles and contributed to a stable workforce. A member of staff told us, “I now work part time, and my request was granted after an initial supervision…”

Staff were treated fairly, with leaders taking a flexible and supportive approach that recognised individual needs and circumstances.

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.

Governance systems had failed to identify all of the concerns we found, for example issues around environmental safety and medicines management. The quality and content of care records and risk assessments was also inconsistent.

The provider carried out regular quality monitoring at the home, but their governance and oversight had been ineffective in identifying all of the issues we found. Where concerns had been identified had not always been addressed successfully or in a timely manner. The registered manager had devised a home improvement action plan and had also introduced a new system of audits. However, more time was needed to make the necessary improvements and ensure those changes that had been made were successfully embedded into working practice.

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. An external health professional told us, “[Leaders] were very good in providing information and carrying out any recommendations. As a team we have never had any concerns with the home.”

The registered manager told us as they had not worked in the area previously, they had requested information from the local authority to ensure they had access to the appropriate resources and services needed to make continued improvements.

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

Quality assurance arrangements were now in place to help identify any areas for improvement but had not always been effective at identifying shortfalls we identified. Although leaders considered information about the service’s performance and how it could be used to make the required improvements, further time was needed to allow the improvements to take shape and embed.

The provider demonstrated a commitment to improving and they acted on any feedback provided during the inspection in a positive and proactive way.

We also received some positive comments from health professionals about how the provider responded to their feedback. One professional told us, “The care home is receptive to feedback and responds appropriately when concerns or errors are identified. The management team and staff are open to discussions about improving practice and are willing to implement recommendations where appropriate.”