Good Shepherd Nursing 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 service. This key question has been rated 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 61 (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. The provider showed experience and understanding of people living with neurological rehabilitation needs. However, the governance and leadership processes in place at Clarendon Court Nursing Home, were not fully embedded sufficiently to be effective.

The registered manager was open and transparent, and acknowledged areas where there were shortfalls. There was a service improvement plan in place to track developments and ensure the required measures were taken to maintain the service to a high quality, safe standard. The registered manager and staff team all had responsibility for ensuring these actions were completed. The registered manager showed a drive to improve the service and a passion to ensure the culture within the service was positive.

The registered manager showed knowledge and experience and understood the context in which they delivered care, treatment and support.

The registered manager spoke of their full commitment to the people and staff team and of ensuring their wellbeing. Their extensive experience in the field of neurological rehabilitation formed the statement of purpose for the service.

The registered manager showed drive and ambition to ensure Clarendon Court Nursing Home was a safe, inclusive place for everyone. They acknowledged areas where improvement was required, and ensured they were open and transparent with people and their relatives about any shortfalls.

The provider fostered a culture where people felt they could speak up and their voice would be heard. However, these processes required embedding to allow any themes for improvement to be identified.

People and their relatives were encouraged to share their views, although this was not formally arranged through regular meetings or surveys.

Where people and relatives had shared their views, we saw the management team had responded appropriately.

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 celebrated and championed their diverse workforce. The provider employed staff from the local area as well as from overseas. The staff team were from varied backgrounds and cultures, and this was reflected in the skills and experience they brought to their roles.

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

Quality management systems at Clarendon Court Nursing Home were not always effective. Information was not always used by the management team effectively to monitor and improve the quality of care. For example, incident analysis records lacked details on the time of day, location, why the incident occurred, and any actions taken. There was no detailed information recorded on any lessons learned. The safeguarding log showed no clear evidence of analysis, lessons being learned, or of these being shared promptly with the staff team.

The electronic care planning system at the service had faults identified by the management team. These left gaps in care planning and daily records, leaving the management team unable to continually audit care outcomes and review these promptly.

We saw a lack of evidence at our assessment showing the provider had identified and mitigated the risks we identified. We were not fully assured the provider could make and sustain the required improvements at the service. Information was not being used effectively to monitor and improve the quality of care. Where the provider’s auditing processes had not identified the shortfalls observed during our inspection, the provider ensured they responded promptly and used the inspection feedback to drive improvement.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement.

The service had a positive approach to partnership working, ensuring they worked collaboratively with external partners. People had access to therapeutic support, from the physiotherapist, and the occupational therapist who visited regularly.

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.

We saw learning from incidents was not routinely shared amongst the staff team to ensure care quality could be improved. For example, there was a lack of robust analysis to look at any further learning required. If improvements were needed to practice, or changes to a person’s care planning, these were not identified promptly to reduce the risk of reoccurrence.

Reflective practice was not used as an effective tool to inform and consistently improve care quality.

The registered manager was fully committed to ensuring future development to enable high quality standards of care. They gave their full assurance to their set timescales for improvements and ensured they were accountable. We will review their actions taken at our next assessment.