SCC Adult Social Care Supported Living and Mallow Crescent short breaks service

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

We identified a breach of regulation in relation to the governance and oversight of the service. Governance and audit systems were not fully embedded into the running of the service which meant concerns were not always identified and address in order to make improvements. Whilst there was an ethos amongst staff of wanting people to be happy, on occasions staff did not referred to people in a person centred manner. There had been a number of changes within the senior leadership team which had led to a lack of consistency and oversight. The current management team were in the process of reviewing systems and developing a strategic action plan to ensure learning and consistency were implemented within the service going forward. The leadership team and staff had developed positive relationships with external professionals and links within the community. Staff felt able to speak up about any concerns and believed the management team would take action to address any issues raised.

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 culture within the service was not always positive as staff did not always see people as their equal. Staff showed an affection for the people they supported. However, there were numerous references and conversations which did not show a person centred approach and did not always reflect staff saw people as adults. This included telling people how they should sit, how boundaries should be set and describing what staff saw as being best for people. Staff frequently described wanting to make people’s lives happy whilst they were staying at the service and many individual interactions we observed were meant with kindness. However, in some instances this was not always person centred. For example, one staff member told us it was an expectation that people were in their rooms by 11pm.

In other areas we found a positive culture where staff were person centred and respectful in their approach to people. This included supporting people’s independence by preparing their own food and supporting people to choose how they spent their time.

We shared these concerns with the management team. They told us they were keen to address these issues and ensure staff had a greater understanding of the positive culture they wished to embed.

There was a lack of management oversight in relation to developing a consistently positive culture in the service. There had been limited reviews of documentation such as people’s daily support notes, care plans, risk assessments or handover information. There were no systems in place to complete observations in relation to the approach of staff when supporting people. This meant the concerns found during our inspection had not been identified and acted upon to ensure a consistent approach and understanding from the whole staff team.

Staff told us they felt supported by the management team. One staff member told us, “[Manager] expects things to be done. When there are clear expectations then you know what to do.” A second staff member said, “The management team are good. They let people know what’s happening all the time.”

Leaders we spoke with were passionate about delivering person-centred, quality care. However, there had been a number of changes in the senior leadership team supporting the service. This had led to the oversight of the service becoming disjointed. The current senior leadership team were in the process of reviewing the needs of the service going forward to ensure new systems being implemented were designed to give greater consistency and support to staff. An action plan had been developed to support them with this process. They told us they would work alongside the training department to develop staff understanding and ability to embed systems and further improve people’s quality of life.

Staff told us they felt able to discuss any concerns they had with their immediate managers and senior leaders. They were aware of who they could go to and how to contact them. One staff member told us, “We have a whistleblowing procedure if we don’t feel able to speak directly to our manager. It’s an independent line so we know it’s in confidence. “The majority of staff we spoke with told us they felt they would be listened to if they raised issues and believed action would be taken. Leaders told us they operated an open-door policy and regularly met with staff to give the opportunity to raise concerns.

Processes were in place to support staff in reporting any concerns. We saw the management team were accessible and held regular staff meetings and supervisions with staff. In addition, the provider had policies in place to support staff such a whistleblowing and grievance procedures.

Staff told us they felt respected by their colleagues and treated fairly by the management team. One staff member told us, “I have always felt supported by them. I have had a number of managers, and they have all been fair.” The management team told us they promoted equality and inclusion through established systems which ensured consideration was given to the diverse needs of the staff.

The provider had systems in place to ensure staff were treated equitably. Training in equality and diversity was compulsory for all staff and robust policies had been developed. Reporting systems were in place and staff were able to tell us how they would report any concerns.

The leadership team told us the overall governance of the service was something they were aware needed to be more robust. Due to the number of changes to the senior leadership, the oversight of the quality of the service had not been consistent. This had led to managers developing their own governance systems and action plans rather than working towards a shared direction.

Audits in relation to the quality-of-care people received were not completed regularly. This included people’s care records, risk assessments, and daily support records. There was no system in place to review the quality of the support people received, how records were maintained or how systems such as capacity assessments were carried out. The lack of a systematic approach meant the inconsistencies found during our inspection such as the approach of some staff, risk management and care plans not always being updated, and best practice guidance not being followed had not been identified and addressed. We found action had recently been taken to update audits although these were not undertaken using a holistic approach.

People told us they were able to choose how they spent their time when staying at the service. One person told us, “I’m going to go out with [staff member] to the cinema. I might go today, or I might go tomorrow. I haven’t decided yet.”

Staff supported people to do things they enjoyed in the local area. Staff told us that although Mallow Crescent was a short breaks service they felt it was important for people to know what was available to them in the area as they may stay on a regular basis. They told us people regularly visited the local garden centre, shops and were invited to attend the local church and a religious group should they wish.

We did not receive feedback from external professionals or stakeholders in relation to this during our assessment.

Processes were in place to foster positive links within the local area and good communication links with other professionals had been built over time. Due to the nature of a short breaks service, there was limited interaction with other service as this was mainly completed by families. However, referrals to appropriate agencies were made as required.

Staff told us they felt they could discuss anything in team meetings, and this would be taken on-board by the management team. The leadership team told us they were aware a more strategic approach to auditing and action planning was required. They told us they would like to do this with stakeholders involved going forward.

An action plan had been developed for the service by senior leaders. However, this did not fully address concerns identified during our inspection such as staff having a full understanding of people’s needs and Right Support, Right Care, Right Culture guidance, how changes to the culture of the service would be managed, how managers would be supported to take greater ownership of governance systems and how action plans specifically relating to the short breaks service would be developed and monitored. Discussions with the provider and managers highlighted they were aware of the need to implement governance systems, introduce electronic records, enhance consistency and ensure people had greater involvement in the running of the service. Improvements were planned to move to electronic recording of daily records and medicines administration which staff felt would be a positive change. However, there was no holistic process to evaluate and plan to ensure continuous improvement.