Our House

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 requires improvement. At this assessment the rating has remained 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.

There was a caring culture in the service. Where staff and the registered manager focused on supporting people’s independence and valued their achievements.

Feedback from people and relatives was valued and staff told us they were well supported.

Although some aspects of governance had improved systems were not yet sufficiently robust and further improvements were required.

Although improvements had been made the service remained in breach of regulations 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.

People told us, "[The staff] are nice" and there was a happy and engaging atmosphere in the service with people laughing and joking with their staff. One person jokingly complained to inspectors, “The staff are loud and annoying.” Relatives praised the service’s culture and one commented, “My relative has been in care since 1998. Our House is the first time we've been able to relax knowing [my relative] is taken care of properly”.

Staff valued people’s achievements, took pleasure in displaying their art works and complimented people on their dress sense. A relative said, “The staff go beyond what is expected to look after [my relative]”.

The atmosphere in the service was relaxed and staff were skilled at providing support discreetly and compassionately. Staff comments included, “I haven’t worked anywhere I have felt this comfortable, this at ease. I have such a good rapport with co-workers. But here I feel it is almost not like going to work, they want it to feel like an actual home. Bit of a shock, sitting with people, chatting and watching TV”, “We have a good network of staff now and it has become a stable staff team with limited turn over. So people get support from consistent staff who they know” and “I have not worked in a place before that I have felt as content as I feel here. There is a really nice ethos in this home”.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

The registered manager did not always provide a strong and positive role model to staff. Records showed that on one day the registered manager had completed 6 different training courses on topics including safeguarding, challenging behavior and the safe management of medications. They had also assessed the competency of 5 staff in the management of medicines. This approach to training by the registered manager is indicative of a ‘tick box’ culture where opportunities for staff improvement and development were not valued.

The service’s management structure had been recently reviewed and 2 new team leaders appointed to support the registered manager and senior carers. The specific responsibilities of team leaders had not yet been confirmed but staff spoke positively about this change. Staff said, “It’s a good place to work”, “[The registered manager] is really approachable, good with the residents, supportive”, “[The registered manager] is lovely as a manager, so approachable as [they] are so involved it is easy to have a conversation about any concern”.

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

People and their relatives knew how to report concerns and had confidence action would be taken in response to any issues they raised. Their comments included, “I would complain to management if had an issue, I don’t have any”, “The manager always sorts things out for [my relative]” and “Gone well when we raised concerns. They were understanding and sorted things”.

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.

Staff consistently told us they were treated fairly and protected from discrimination. They described the registered manager as, “lovely” and “approachable” and reported that requests for flexible working and reasonable adjustments were looked on favourably.

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.

During our previous inspection we found the provider’s governance systems were ineffective and had failed to ensure compliance with the regulations.

At this inspection we identified some improvements in the service’s performance and the effectiveness of governance systems. Previous breaches of the regulations in relation to environmental safety and recruitment practices had been resolved. Some improvements had been made in relation to the management of risk and staff training but further improvements were required to achieve full compliance with these regulations.

The registered manager had commissioned the works necessary to make significant improvements to the quality of the environment and ensured improvements to the cleanliness of the service were maintained.

Effective systems had been introduced to ensure staff completed allocated training and the service training matrix showed 96% of training allocated had been completed. However, specialist training in supporting people with learning disabilities and autism had not been identified as a need and had not been completed.

The service was using a digital care planning system but had failed to record details of incidents between all people involved in any incidents that occurred. In addition, systems for alerting the registered manager to incidents that had occurred were not robust and necessary notifications detailing incidents had not been submitted to the Care Quality Commission.

Records of purchases the service had made on people’s behalf and of financial transactions between the service and individuals in receipt of support had not been accurately maintained.

Protocols detailing when staff should give ‘as required’ medicines were unavailable. Prior to the assessment the registered manager identified from care records disparities in relation to the use of ‘as required’ medications by a particular member of staff. As a result of these investigations changes were made to the staff member’s role and responsibilities to ensure people’s safety. However, formal records of this investigation and the registered manager’s decision making had not been maintained. The failure to record this detail meant opportunities to learn from the incident, identify future patterns and mitigate further risk may have been missed.

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 engaged positively with health partners, community activity providers and relatives to meet people needs and expectations. One person regularly attended a community based voluntary work placement and the provider was actively investigating other opportunities for people.

Two people enjoyed regular trips out to visit local attractions and people told us staff had supported them to visit the local town to go shopping. A new minibus was purchased following the inspection to increase people’s access to the community.

The service worked flexibly during weekdays, to enable people to maintain relationships that were important to them. Staff were regularly supporting a person to visit their relative at home as changes in the relative’s needs meant they were no longer able to visit the service.

The provider did not always focus on continuous learning, innovation and improvement across tute to safe, effective practice and research.

The registered manager had been supported by the provider to improve the servicehe organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contrib’s performance and necessary investments had been made to the environment of the service. In addition, the registered manager had engaged positively with the local authority’s Quality Assurance Team and had taken action to address issues raised during feedback as part of this assessment. However, the service’s systems for documenting and reporting incidents were not robust and this meant opportunities for improvement had been lost.