Sunningdale Court-Care Home

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• 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 the governance at the service.

This service scored 46 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The culture of the service was not always person-centred, open, inclusive and empowering. Although the provider had set organisational aims and objectives, leaders did not always model or uphold them in practice. The service was not consistently aligned to its values. For example, they had not ensured that people were supported holistically and enhanced people’s lives whenever possible. This meant the provider could not demonstrate a shared direction or culture that supported high quality, person centred care. A staff member said, “People miss out and the service is not for the people.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Feedback about the service’s leadership was inconsistent. Relatives reported positive experiences of the leadership and management team and said, “Management is very approachable,”. Staff feedback varied; some staff identified positive improvements, while others reported difficulties engaging with leaders.

People did not always feel they could speak up and that their voice would be heard. Staff did not consistently feel confident or able to speak up within the service. While staff told us they understood how to raise concerns and could approach senior managers if needed, some reported they did not feel comfortable doing so or that their concern would be listened to. The provider had a Raising Concerns, Freedom to Speak Up and Whistleblowing Policy and Procedure in place. However, the policy did not reflect best practice guidance as it did not signpost staff to an individual who was independent of the management structure.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Not all staff felt they received fair and equitable treatment. Feedback from the staff team varied whilst some staff felt there was treated fairly, other staff did not. The provider did have systems in place to identify and review staff needs, including regular supervision and team meetings, where individual circumstances and required adjustments could be discussed. However, not all staff felt these were beneficial and staff did not always feel listened too.

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.

Governance systems were not robust or effective in supporting day‑to‑day quality assurance or driving improvement, and audit activity was not used meaningfully to monitor performance or service quality. The monthly governance was not always completed, and were there were shortfalls found, the registered managed did not take responsibility for these tasks and ensure action was taken. Actions that were identified had not been completed in a timely way. For example, an action was listed as providing menus for people, but this had remained as an incomplete action for several months.

Daily records were short, task orientated and lacked detail. There was no clear oversight of this. The registered manager had identified and raised these concerns in a team meeting to the staff team. However, there was no clear follow up action and daily records still continued to be short, task orientated and lacking in detail.

The registered manager did not ensure policies were always followed. For example, agency staff required an induction to the service, as documented in the providers policy, but this was not completed.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

Where people had been referred to healthcare professionals, there was limited information to evidence their advice had been followed as daily records did not have the appropriate information documented. Furthermore, the provider did not always follow up appointments, such as chiropody, in the appropriate time frame. There were also limited opportunities for people to interact as part of the community. A professional highlighted “Whilst staff listen to suggestions/recommendations regarding communication, implementation is not always consistent. This is likely impacted by the lack of staff.”

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.

The lack of oversight of systems and processes meant that concerns were not consistently identified or addressed, limiting opportunities for learning and improvement. As a result, there was little evidence of lessons being shared with staff to support improved practice.