Pinglenook Residential 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.

This is the first assessment for this newly registered service for this provider. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. The service was in breach of legal regulation in relation to good governance. Systems and processes in relation to auditing, monitoring and quality assurance were not sufficiently robust.

This service scored 57 (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 and new manager had not yet fully implemented a robust strategy and culture at the service, although were working towards this. Effective engagement with people and relatives required improvement. For example, a consistent approach to residents and relatives’ meetings, and quality assurance was needed. This meant people and relatives could be more involved in the direction of the service based on the feedback from them we received.

The provider and manager were open and transparent and a positive culture to equity, equality and human rights, diversity and inclusion, and understanding challenges and the needs of people and their communities was in place.

Staff did have opportunities to engage with the manager through formal and informal meetings and said this was constructive and beneficial to them.

We were not fully assured at the time of the assessment the provider and new manager lead the service effectively from the shortfalls we identified. The provider was not available to support the new manager at the beginning of their tenure which began a short time prior to the assessment. This was a missed opportunity to ensure a smooth and detailed handover could have taken place. The provider and manager were open and honest in their engagement with us, accepting the shortfalls we found, and sought to resolve them promptly. At our next assessment we will review this again to assess the necessary improvement has been embedded.

A positive culture where people felt they could speak up and their voice would be heard was in place. Staff knew how to raise concerns and were confident action would be taken. Staff told us they felt they had the freedom to speak up. The provider had systems and processes in place to enable staff, and their relatives to speak up.

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. There was a diverse staff group at the service. All staff we spoke to told us they were treated fairly and equally.

Oversight of the service required improvement. Whilst the new manager had identified some areas for improvement, additional support from the provider during this managerial transition could have enabled these improvements to have been identified and acted upon sooner. For example, gaps we found in audits of the service, typically those related to health and safety and the environment corresponded with the shortfalls we identified in these areas. Improved organisation and archiving of some records in the office was also required to make access to current information easily accessible. There was not a CQC registered manager at the time of our assessment. However, the provider had very recently recruited a new manager who told us they had applied to the CQC to become the registered manager. The manager was visible, knowledgeable, and supportive across the service, and had begun to forge good relationships with people, relatives and staff who all provided positive feedback about their managerial approach.

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 provider told us relationships which they held with health and social care agencies was positive. We sought feedback from these agencies who confirmed this. The provider and manager had successfully completed an action plan recently with the local authority to make the required improvements they had identified.

The provider and new manager were focusing on areas of improvement they had identified to improve outcomes and quality of life for people across the service. We also found areas of improvement required. Our discussions with the provider and manager assured us there was a clear commitment to make these improvements and they had plans in place for these improvements to be made. We will assess that these improvements have been fully embedded at our next assessment.