Shottendane 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.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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.

The provider communicated the service’s vision to staff through training sessions, induction programmes, and newsletters. The nominated individual also shared this vision with us, explaining that they were working to create a culture where staff feel empowered and confident in their roles. To support this, they developed a range of training programmes designed to help staff meet people’s needs effectively.

People using the service and their families told us they had noticed improvements since the new provider took over. One relative said, “We had a few issues at first, but improvements have been made.” Staff also spoke positively about the changes. One staff member shared, “It’s a good place. I visited before my interview and thought, ‘I’d like to work here’. They’re keen to improve, and the atmosphere feels good, which is very important to me. I enjoy my job.” Another staff member added, “I’m learning a lot here. Management is trying to improve the service, and they genuinely care about the residents.” Professionals we contacted echoed this positive feedback. One commented:
“I feel the management is proactive and committed to improving the service.”

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 registered manager was responsible for 3 services and divided their time between them. They were supported by a deputy manager who had experience working in the service and is a registered nurse. The nominated individual also regularly visited the service to provider support and direction to staff. People told us they knew who to approach if they had concerns. One person said, “I know who’s in charge. If I want to speak to them, I ask the carers to let them know, and they come.” A relative commented, “The management is approachable, and the nursing home is improving.”

Staff reported feeling supported in their roles. One staff member shared, “The management team is approachable. I can speak to the registered manager or the deputy manager. I feel supported and can ask any questions.” Another added, “The deputy manager does my clinical supervision, and she’s excellent. She’s very engaged and available, we can go to her for anything and call her anytime.”

Regular staff meetings and handovers were held to share updates on operational matters and address issues affecting the smooth running of the service. The registered manager understood their regulatory responsibilities and complied with requirements, including notifying the CQC of incidents as required by their registration.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. One staff member told us, “I know the procedure for reporting concerns. There’s a dedicated phone line to report abuse or raise issues, and I would use that if needed.” Another staff member said, “I usually speak directly to the registered manager, deputy manager, or human resources manager about any concerns. I feel comfortable speaking up and involving external organisations if necessary.”

The provider had clear policies and procedures in place to support staff in raising concerns. The registered manager explained that they operate an open-door policy, welcoming staff and visitors to share concerns at any time. We observed the registered manager encouraging staff to complete anonymous surveys. Additionally, the provider had a system that allowed staff to raise concerns anonymously.

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.

Records confirmed that staff had completed training in equality and diversity, and staff reported feeling supported within the team regardless of their background. The provider had an equality and diversity policy in place and employed various strategies to promote inclusion in the workplace. For example, they supported staff who were new to the UK by helping them integrate and pairing them with buddies to assist with settling into their roles.

The registered manager stated that training and mentoring opportunities were available for staff who wished to develop their skills and progress in their careers.

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 completed various audits and checks to identify improvements needed in the service. The nominated individual carried out monitoring visits to the service monthly to assess the quality of the service delivered. They spoke to people, staff and observed the environment and care delivered. The provider had recently commissioned an external organisation to carry out an assessment of the service looking at various aspects of the service.

We found that there were audits and quality checks available including medicines audits, health and safety, call bell audit, staff training and supervision audit, pressure sores monitoring, falls monitoring, fluid and food chart record audit. However, these audits had not effectively identified some of the issues found at this inspection. For example, repositioning charts were not always completed. This had been identified as an issue by a professional previously. Airflow mattresses were not always checked to ensure they were set correctly for people. Charts for people’s bowel’s movement were not always monitored to ensure that concerns were picked up promptly and actions taken to address concerns. Staff were not always following the systems in place to raise and discuss concerns about people. For example, the daily care meetings did not prompt discussion or remind staff to raise concerns about people specifically.

Following our feedback on the first day, we observed on the second day of our visit that staff had checked and corrected the settings on people’s pressure‑relieving mattresses, and the mattress audit had been updated to include verification of these settings. The registered manager also shared handover and daily flash meeting records, which showed that this had prompted discussion and review of people’s bowel charts. We also discussed these concerns with the provider and registered manager during our feedback, and they confirmed that immediate actions had been taken to address and improve these areas.

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 service worked closely with local service commissioners, the NHS Clinical Commissioning Group, and health and social care professionals to improve the service delivered to people. The service had links with local community. They organised events and activities within the service that were attended by people, their families, staff, and members of the community to help strengthen relationships, reduce isolation, and promote social connection.

The provider had not always 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 had implemented a service improvement plan to address previously identified shortfalls, with a particular focus on staff development through training and reflective practice. They were also in the process of converting policies and procedures into podcast formats to enhance accessibility and understanding for staff.

However, during this inspection, we noted ongoing concerns that had been raised previously. These included repositioning charts not being consistently completed and staff failing to act promptly to provide necessary support to individuals known to have specific health conditions.