Spennymoor Care Home Limited

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 the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We identified a breach of regulation 17 regarding good governance.

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 understandingchallenges and the needs of people and their communities.

The provider told us about some of the core values of the service which included prioritizing quality of care, dignity, compassion, respect, independence, privacy. Throughout the assessment, we saw these were upheld by staff when interacting with people.

Staff spoke of a positive culture within the service. One member of staff said, “It is really good working here to be honest. Everybody is really nice and gets on well together.” Another member of staff said, “I really enjoy it here. Management and all the residents are so nice.”

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.

We identified a breach of regulation 17 regarding good governance. This was due to concerns identified regarding care planning, risk assessments, fire safety and seeking consent. There had been no impact on people living at the home however and we felt this mainly related to oversight within the home.

The registered manager, who was also the provider, had over 20 years' experience and a strong background in care, having started as a care worker at the age of 16 and progressed to a senior role before purchasing Spennymoor. They held an NVQ Level 3 in Health and Social Care and has been a CQC registered manager since 2006.

The registered manager maintained a visible and accessible presence within the service, working on-site five days per week and operating an open-door approach. Staff were encouraged to discuss any concerns or seek support at any time and had access to the manager's contact details for out-of-hours guidance when required. Regular staff meetings provided opportunities for open communication, enabling staff to share feedback, raise concerns, and contribute to the ongoing development and improvement of the service.

The feedback we received from staff was that there was good management and leadership within the service. One staff member said, “There is very good management at the home. It’s just how approachable they are. Any issues it gets sorted. They will come in if we have any problems in the night.” Another member of staff said, “The [registered] manager is brilliant, supportive and easy to talk too.”

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

Staff knew how to whistle blow and they felt confident to speak up should they need to. The provider had a whistleblowing policy available to staff. Staff were able to raise any concerns in team meetings, or directly with the management.

The provider valued diversity in their workforce. They worked towards an inclusive and fairculture by improving equality and equity for people who worked for them.

Staff told us they felt they were treated fairly, including those from different ethnic backgrounds, and worked well with the wider team.

Staff completed training in equality and diversity and understood what it meant. Staff were kept up to date with issues affecting the overall service via team meetings and on-going conversations.

Recruitment and disciplinary processes were clear and ensured there was no disadvantage based on staff's specific protected equality characteristics. The provider had processes in place to ensure an inclusive workplace where staff were treated and supported as individuals.

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.

There were a number of governance systems in place, including the monthly audits of areas such as medication, falls, the environment and infection control. However, the provider said they didn’t carry out audits of care plans and we found lots of missing information in the ones we looked at during the inspection. We also found mental capacity assessments were completed for all decisions relating to people’s care. Risk assessments also were not always in place for some areas, such as choking. This could have been identified had care planning audits been in place.

Regular nighttime spot checks did not appear to take place. The provider advised that these were completed, however they were not documented. Competency assessments were carried out regarding medication, however these were not completed for safe moving and handling techniques.

At the time of the inspection, there were 3 approved DoLS authorisations in place, although notifications had not been submitted to CQC. The provider also needed to submit a notification to CQC to add the service user band ‘Dementia’, as this impacted several people living at the home. The provider told us these would be submitted.

Accurate records were maintained regarding people’s support in relation to oral hygiene, re-positioning and personal care.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider told us they did not have any current links with the local community. However, some people living at the home received visits from the local priest. The home had also been approached by local schools who had volunteered to sing carols at Christmas.

The local authority told it was sometimes difficult to engage the home with collaboration, and they did not take part in ongoing initiatives or attend forums.

The provider worked in partnership with other organisations such as district nurses, SaLT and dieticians. People also told us about receiving support from these services when needed.

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.

Staff and leaders have did not have a good understanding of how to make improvement happen. There were gaps in the systems to support improvement. Records to support people’s involvement were limited. There was no improvement plan to support the home with continued development or how people and relatives contributed to this.