EVHM LLP - 6 High Beech Close

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 75 (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 registered manager spoke about the importance of being open and transparent with people, relatives and staff. She spoke about the need for good induction for all new staff, staff being good role models and making sure that everyone was involved in and informed of any changes. In terms of equality and diversity she felt as a service they were good at recognising that every person had their own values and opinions and they captured people’s opinions via their care planning process by making sure they were person centred.

Staff understood the home’s vision and values and had opportunities to share their views on the running of the home via supervision and staff meetings.

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 told us they felt supported by senior management who visited periodically to audit the service and to provide ongoing support.

Staff were clear about the role and responsibilities of each staff member, and they knew how to get support when they needed it. A staff member told us, “I’ve worked with [registered manager] a long time, we are honest with each other and a good team. I couldn’t ask for a better manager.” Another told us how they had, “Progressed a lot since working here and I’ve grown in confidence.” They told us this was due to the training received but more importantly the support they received from the management and staff team.

The feedback received from professionals was very positive. One professional told us, “Management team approachable, available and very much part of the staff team. From what I have seen when visiting, the staff team treat each other with dignity and respect.”

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

There were ample opportunities for people, staff and visitors to share their views. Staff were aware of the whistleblowing policy if they had any concerns and they told us they would have no hesitation speaking up if they needed to. They felt confident that action would be taken. They had opportunities to share any concerns or suggestions for improvement through supervision meetings and house meetings. People had opportunities to share their views through keyworker meetings and house meetings, and they told us they could speak with the registered manager or deputy when they needed to.

A relative told us they had a good relationship with the registered manager. They said, “I can contact her if I have any concerns, we made a request in the past and we were listened to. All is as it should be. [Person] regards it as her home, she loves it there and we are very pleased with her home.”

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.

People were cared for by a diverse staff team. Staff told us the registered manager and deputy recognised their individual needs and respected them. Staff gave examples of being encouraged to prioritise their own health, manage family commitments, and request time off when they needed this. Staff told us that management responded flexibly and were supportive.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were good systems to ensure oversight of the service and any risks, along with monitoring the quality of people’s care and support. Fire drills were carried out regularly and

records showed how people responded when the alarms sounded but did not record staff performance. A new format for recording this information had very recently been implemented but this had not yet been completed. Staff were able to tell us what they would do in the event of a fire.

The service has a system in place to carry out annual surveys to obtain views from people, relatives, staff and professionals. Responses from staff were low and the registered manager said they would look at the formats used in an effort to increase the response. This had a low impact as staff had several ways to share their views on the running of the service.

There were clear policies and procedures and staff followed these. The provider was aware of their statutory responsibilities to notify CQC about certain changes, events and incidents that affected their service or the people who use it. These notifications were submitted appropriately.

There were systems to carry out regular audits of the service to make sure it was running effectively. The quality assurance lead carried out 1 or 2 provider visits annually and any shortfalls were identified in an improvement plan. Follow up desktop reviews were then carried out to review progress with the improvement plan. The registered manager spoke about the continuous cycle of assessment and review and how they were making improvements all the time because of this regular focus. The provider also had a business continuity plan, to help ensure the service could continue running during and after any disruptions.

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.

There was regular engagement with people and their families, and the service worked hard to create links with local communities. The registered manager told us she continued to attend a regular network meeting for registered managers.

Health and social care professionals were positive about the service’s approach to partnership working. They described effective collaboration between staff and external teams. There were weekly ward rounds with the local GP service and staff knew they could contact the surgery at any time if they had concerns or worries about people’s health or wellbeing. In addition, they worked closely with the local learning disability team and had a range of support from allied therapists. A health professional told us, “There is good communication between staff on the ground, management and health professionals that work in the service.” Another professional told us, “6 High Beech Close seek to ensure they have all the required information and are happy to seek further advise or assistance in order to develop guidelines and ensure continuity of care.”

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 management team were open, transparent and engaged positively throughout the inspection. They acted immediately on any areas of improvements we identified. They welcomed feedback and demonstrated a clear commitment to continuous learning and improving the quality of care.

The registered manager, deputy and senior staff reviewed audit findings together, ensuring they had clear oversight of the service and could identify areas for improvement.

Staff were committed to learning about people’s individual needs and how their changing health conditions might affect them. This included seeking guidance from other health and social care professionals to better understand and meet people’s communication needs.People had welcomed the opportunity to participate in a health and well-being group run by the local learning disability team. This group focussed on aging and helping people to understand changes that were occurring to their bodies and how to stay healthy. One person told us they learned a lot through the group, and it helped them to know that what they were experiencing was normal and it was ok to not always feel ok.