The Star 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant that management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. However, leadership acted promptly and effectively when issues arose.

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. 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.

Staff told us they felt the home had a positive, open culture. They told us that senior leaders were visible and approachable. Staff talked about their community spirit and the importance of meeting the needs of people from diverse backgrounds with complex needs. Leaders promoted people’s equal rights and ensured there were no workforce inequalities.

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. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders had not identified that tools in place were not adequately completed, for example medicines audits, staff observations and staff dependency calculator. Leaders had not recorded out of hours observations they had completed.

However, leaders were visible within the service and there were opportunities for people to meet the manager. The service user guides and newsletters provided information about the manager with important contact details. Leaders identified issues during the inspection period and acted quickly.

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

The majority of people felt comfortable raising concerns and said they would be listened to.

One person told us, “I haven’t made any complaints or anything. I know the staff would take it seriously if I did mention anything.” One relative told us, “I have only raised small things and they have always been sorted. I speak to any of the staff here.”

There was a ‘raising concerns and freedom to speak up’ policy in place that was part of the staff induction programme. Team meeting minutes showed that staff were comfortable sharing their feedback and management listened. Staff told us that managers were supportive and available. One staff member told us “We have monthly supervisions which are helpful, helpful manager very helpful and understanding.” Another staff member told us “I feel comfortable to give feedback, manager is so lovely”. The provider had a ‘Speak up’ video that was shared with staff.

However, despite people feeling able to share concerns some relatives told us they felt staff communication and responsiveness could be improved.

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.

We spoke to staff from diverse backgrounds and staff who were on care worker visas who all said they were made to feel welcome and felt valued. Recent Workplace Equality, Diversity and Inclusion survey analysis had been completed.

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

Although internal audits were conducted, they did not identify issues observed during inspection, raising concerns about the effectiveness of governance and oversight processes.

Effective audits of the medicine administration records (MARS) had not taken place. This meant that errors in the administration of medicines had not been identified, and the necessary action taken to investigate to ensure the safety of people.

We found the provider’s care monitoring documents were not sufficient. For example, where people required support with positional changes to reduce the risk of pressure sores, we found the charts had times pre-populated, which increased the risk they would not be accurately completed.

There was evidence that staff liaised with other professionals including GP and Social Workers. However, there were times when records were not updated following liaison with health professionals.

Leaders took prompt action once issues were identified including reflective supervision with staff, safeguarding investigations and reviews of documentation.

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.

We saw evidence of effective partnership working with external professionals and we saw evidence of effective information sharing and collaboration. For example, for 1 person who’s mental and physical health had deteriorated the provider had collaborated with their psychiatrist, social worker and GP to improve their health.

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.

The service did not always involve people, their relatives, and staff in developing and improving the service. The home had provided support to a high number of people at the end of their life. Despite advising that they had specialist skills and followed end of life frameworks to ensure quality care for people at the end of their life, we saw little evidence of this. There was no evidence that the home tailored activities to people’s individual interests or that people were involved in care home routines for example gardening. A high number of people spent their time in one communal area when they might benefit from a quieter space.

However, there was a comprehensive home action plan in place and the provider was completing regular quality assurance visits and reports to make improvements at the home. Corrective action was taken quickly following inspection findings.