Sylviancare South Gloucester

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. We found improvements were needed to the providers governance arrangements around care planning, incidents and accidents, and the providers statement of purpose. The service was in breach of legal regulation in relation to governance at the service.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service 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. The registered manager wanted to provide the best care possible to people and did this through providing staff with opportunities for learning and further development. People felt supported by staff who were respectful, kind and caring.

Staff were supported by a registered manager who was also the nominated individual for the service. They were available and approachable to staff as they worked within the office. There was also a senior manager who supported the nominated individual and a care co-ordinator who undertook the role of care planning and support for staff within the community. All staff were positive about working for the service and the support they received. One member of staff told us, “It’s a nice place to work.” Another member of staff told us the support from management was, “Very good, excellent.” The service had inclusive leaders at all levels who managed the service in an open and honest way.

The service had a positive culture where staff felt they could speak up and their voice would be heard. The registered manager spoke about the culture being positive where staff felt supported and able to speak up if they needed to. Staff had regular meetings, supervisions and the opportunity to feedback through staff surveys. Staff felt supported and able to discuss any concerns with the management of the service.

People were supported by a diverse workforce and the registered manager provided staff with training and further development so they had the skills and knowledge to undertake their role. The registered manager recognised the importance of supporting staff flexibly and they gave an example where one member of staff was provided with time off to undertake a further development qualification.

The service was managed by a registered manager who knew people and staff well. They had recently appointed a new quality lead who would be undertaking quality assurance checks within the service. Although the registered manager had good knowledge of the service, we identified the providers quality assurance systems had not always identified the following shortfalls. For example, we found 2 people’s care plans needed a risk assessment to provide staff with guidance on how to support the person with their equipment and mobility. Where the registered manager reviewed incidents, accidents and safeguarding the quality assurance system did not always clearly document all information and what actions had been taken by the service. We found 1 notification had not been sent to CQC as required. The governance arrangements had also failed to identify where people’s care plans needed more information on how staff were to support them with their diabetes care, catheter care and bowel care. We also found documentation such as an up-to-date statement of purpose confirming the objectives of the service were not in place and had not been sent to us prior to our assessment. The provider also needed to ensure they sent CQC important information about changes to the service. We shared this feedback with the registered manager who took action to address these as required. Some areas of improvements had been identified by the provider. This included care plans having important information within them. Although the provider’s audit had identified these actions were needed, we found during our assessment improvements were still required.

The service worked in partnership, so people achieved the best outcomes possible. They shared information and learning with partners and collaborated for improvement when needed. The registered manager sought feedback from people, relatives and external professionals so they could provide the best care possible. The registered manager wanted to develop the service further and how it contributed to the community and partnership working and they were exploring ways they could do this.

The registered manager provided staff with continuous learning, innovation and improvement. This was through regular staff supervision, meetings and discussions. All staff we spoke with felt supported. Some improvements were needed to the providers documentation so it was clear what improvements and actions had been taken when incidents, safeguarding and concerns had been raised. We shared this feedback with the registered manager so they could review how was best to do this.