Saivi House

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.

Throughout the assessment, we observed staff treating people with compassion and kindness. Staff understood the principles of equality and the provider promoted a culture of shared direction. This was discussed in staff meetings and as part of staff supervision. The registered manager and staff were positive around promoting people’s rights and helping them lead a fulfilled life.

Leaders were inclusive and understood the context in which they delivered care, treatment and support. The registered manager had the skills, knowledge, experience and credibility to lead effectively.

Staff described the registered manager as ‘Firm but fair’ and said “If they [staff] haven’t done something of course [the registered manager] will pull you on it, it’s her job. We call her so much throughout the day sometimes!”. Staff told us they felt supported and confident in doing their job and were supported well by the registered manager. A staff member said, “[The registered manager] has taken so much time to explain everything and make me feel confident.”

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

Staff understood what whistleblowing was and how to whistleblow of they felt they needed to. Staff told us they were able to go to the registered manager at any time and felt listened to. There were regular staff meetings where staff were able to discuss and issues and ideas and have their voice heard.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

There was a clear management structure in place which staff understood. There were numerous audits completed to monitor the quality of care and governance of the service. These included audits of care plans and people’s care files, infection control, health and safety, including fire safety and environmental audits. The registered manager understood their responsibilities to notify CQC of any incidents or concerns.

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.

Staff worked well with other healthcare professional in the best interests of people.

The provider focused on continuous learning and improvement across the organisation.

At the time of the assessment, the provider had been placed into the local authority provider concerns process. This is a process where concerns around care have been identified, and the home is subject to increased monitoring. Managers and provider of the home met with the local authority regularly to help improve standards of care. The registered manager provided the local authority with an action plan on how they would address concerns. During the assessment, we saw care plans, risk assessments and other documentation had been reviewed. Staffing had been increased by1 extra staff every day. We found the quality of care to have improved, and the provider had worked with the local authority to address the concerns.