Shaws Wood Residential Care 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 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 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. However, we received mixed feedback from staff about the culture of the service.

Some staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Other staff told us, they did not feel empowered to raise concerns and said they did not always feel listened to. Comments included, “We feel moaned out all the time and not praised. This should be a rewarding job. It is never a ‘well done girls’. I don’t think anything changes from the surveys”; “The culture is open and supportive” and “We do raise things, if there is no solution, you just say no to raising issues.” Some staff had reported this in a staff survey. The provider was looking at ways to tackle this. Some actions had already taken place, such as creating a deputy manager role.

The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The provider has detailed on their website, ‘Our mission is to provide excellent care respecting each person as an individual, supporting people of all or no faith to meet every physical, emotional and spiritual need’ and ‘We look to partner with relatives, friends and the local community, schools and churches to create a home in which our loved ones can still feel part of a community if not independently able to live in it.’

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The management team knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with the registered manager and a deputy manager. The service also employed senior care workers and care workers to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the nominated individual for the provider. They were based at the service and undertook checks and audits. The management team told us they were well supported by the provider. Daily handover meetings were held so staff had up to date information about the people they were supporting.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “I do feel confident to whistle blow.” Another staff member told us, “It’s an open door policy, we can talk about anything to our manager, and she will deal with it quite quickly. She has always said whistle-blowers would be protected.”

Complaints processes were available. People knew who to talk with if they had concerns or complaints. A person told us, “I have made a complaint recently about a member of staff the manager responded with a letter the next day and am waiting to have a meeting.”

Relatives knew who the registered manager was. Comments included, “There has always been someone there I can speak to”; “If I need to speak to someone, they always do give me a call” and “The manager is accessible.” A relative raised they did not always get an answer or feedback from written complaints letters; however, they did get a response to emailed concerns or complaints.

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. However, feedback from staff showed this did not always work in practice.

Some staff told us any issues could be discussed openly at staff meetings or during supervision. However, some staff reported concerns. The provider had processes in place to encourage an inclusive culture. The registered manager told us they had an open-door policy. Staff told us about the support they had been given in their roles. We received mixed feedback from staff. Some felt well supported and some did not. Comments included, “If we had more staff, we would definitely have time to chat, and it would not be as stressful. We have definitely brought this up with management on many occasions and it’s not been looked at”; “I feel the support we should get to the support we do get is very different”; “Support from management varies. I can’t really say yes to receiving good support. It takes someone with empathy and compassion who knows staff to recognise if staff are ok. It’s a bit one sided. Some staff have gone to [nominated individual] to voice as a team but still don’t get results.” We fed these concerns back to the management team. The provider told us that further improvements to communication and management presence was planned.

The workforce was diverse, and support was in place for staff. The registered manager ensured staff with protected characteristics were supported with any reasonable adjustments if required. For example, altering shifts and working times to accommodate childcare arrangements and religious needs.

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.

The provider had systems to check the quality of the service. Audit systems were in place, and we found that actions had taken place to address some issues. However, care plan audits had not been taking place so issues with inconsistent and out of date information had not been picked up by the management team. Although we were not aware of any direct impact to people, there was an increased risk to people as the service used agency staff who did not know people as well as the provider’s staff. Infection prevention and control audits had identified issues with the flooring, however the actions to address this had not been prioritised over other issues. The fire doors and telephone system upgrade were prioritised. The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices. These were protected by passwords, so that only staff who had been authorised to access the information could do so. The provider had displayed their last inspection rating on their website and within the building.

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. The management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with GPs.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the provider updated CQC on the progress of these actions.