Euxton Park 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.

This is the first assessment for this service. This key question has been rated requires improvement.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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. They did not always understand the challenges and the needs of people and their communities

Staff described a positive and supportive culture within the service and were committed to providing good quality care for people. They understood the values of the service and spoke about the importance of treating people with dignity, respect and compassion. Staff worked well together and felt able to approach managers and colleagues for support.

Staff acknowledged that the service had experienced several management changes over recent years, which had at times created uncertainty. However, staff said, “Many of the changes introduced have resulted in improvements to the service.” Staff felt that leaders were working towards a shared goal of improving outcomes for people and creating a positive environment for both people and staff.

People and relatives were generally positive about the culture of the home. Feedback showed that staff were caring and responsive, and relatives felt able to raise concerns or discuss issues with the management team. Staff felt listened to and included in discussions about the service, which helped them contribute to ongoing improvements.

The provider encouraged staff development through training opportunities and specialist roles, such as Champions for key areas including safeguarding and infection prevention and control. This helped to promote good practice and created opportunities for staff to take ownership of areas of service delivery.

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.

At the time of the inspection, the service did not have a registered manager in post. A temporary manager was leading the service while the provider completed a recruitment process. People, relatives and staff were aware of the management arrangements and knew how to raise concerns or seek support when needed.

Staff felt able to speak openly with the leadership team and were confident their views would be listened to. They described managers as approachable and supportive. While staff expressed some apprehension about the appointment of a new manager and the potential for further change, they also recognised that positive improvements had been made under the previous manager's leadership.

Relatives said they knew how to contact members of the management team and felt able to raise any concerns or questions. People also spoke positively about their interactions with leaders. A person said, "I have met the manager today and she seems nice."

Overall, leaders were visible within the service and promoted an open culture where people, relatives and staff felt able to share feedback and concerns. Although the absence of a registered manager created some uncertainty, the provider had arrangements in place to maintain oversight of the service and support its continued improvement.

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

A whistleblowing policy was in place. Staff said they would feel confident to raise any issues, and these would be listened to and acted upon. Staff were able to raise concerns in their supervisions and at team meetings.

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.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. Staff had no concerns about discrimination, and staff confirmed they felt respected and supported.

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.

The provider had systems in place to monitor the quality and safety of the service; however, these were not always effective in identifying concerns in a timely way. As a result of our findings, the provider was in breach of Regulation 17 (good governance) and was required to submit an action plan to address the issues identified.

Although audits were completed and had identified some areas requiring improvement, management oversight was not always robust. For example, care plan audits had identified missing information about people's medical conditions and outdated dietary information, and records showed that action had been taken to update these. However, we found some dietary information had not been reviewed or updated for two years before this was identified. This demonstrated that governance systems had not been effective in ensuring records remained accurate and up to date.

We also found gaps in other monitoring processes. Management were unaware that maintenance checks for profiling beds were not being consistently documented. In addition, audits were not consistently identifying when risk assessments required review following incidents. This meant opportunities to learn from incidents and reduce future risks could be missed.

While leaders demonstrated a willingness to make improvements when issues were identified, the concerns found during the inspection showed that quality assurance systems were not operating effectively enough to provide consistent oversight of care records, risk management and equipment safety. This placed limitations on the provider's ability to ensure safe, effective and sustainable service delivery.

Overall, governance arrangements required improvement to ensure concerns were identified promptly, actions were monitored effectively, and quality assurance systems provided managers with accurate oversight of the service.

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 worked in partnership with a range of healthcare professionals and community services to help ensure people received coordinated care that met their needs. Staff worked closely with GPs, district nurses, community healthcare teams and other specialists to support people's health and wellbeing and respond to changes in their needs.

People were supported to maintain relationships with those who were important to them. Relatives were kept informed about changes in their family member's health and care needs and felt involved in decisions where appropriate.

The service recognised the value of partnership working and made referrals to external professionals when additional support or advice was required. Information was shared appropriately with relevant agencies to help ensure continuity of care and positive outcomes for people.

Overall, the provider demonstrated positive partnership working with families, healthcare professionals and community services. These relationships helped support people's health, wellbeing and involvement in the wider community, although there were opportunities to further develop community links and engagement for some people.

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.

The provider demonstrated a commitment to learning from incidents and using this learning to improve practice across the service. Managers shared learning from events that had occurred within the provider's wider organisation and took action to reduce the risk of similar incidents occurring at this location.

For example, following an incident at another of the provider's services, improvements were made to the diabetes policy. The management team reviewed all diabetic care plans to ensure guidance was current, accurate and reflected people's individual needs. This helped to strengthen oversight of diabetes care and ensure staff had access to up-to-date information.

The provider also responded proactively to learning identified in relation to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. The management team arranged additional training for staff to improve their understanding of DNACPR documentation, what a DNACPR decision means, and the circumstances in which cardiopulmonary resuscitation (CPR) may still be appropriate where there are reversible causes.

These actions demonstrated that the provider was willing to reflect on incidents, learn from events occurring both within and outside the service, and implement improvements to support safer and more effective care. Overall, systems were in place to encourage learning and continuous improvement, and staff were provided with additional guidance and training when areas for development were identified.