Mile Oak Rest 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

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 provider’s vision and culture were shared with staff in the staff handbook and clients in the client handbook. All staff worked in collaboration to ensure a quality service for the people.
The registered manager ensured staff delivered care in line with those values during regular spot checks and supervision sessions. Staff showed a strong understanding of the shared direction, demonstrating it was well embedded and effective.

The management team operated an ‘open door’ policy where people, relatives and staff could speak to them at any time to ensure there was an open culture where concerns could be raised and acted upon.
 

The provider had exceptionally 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 always did so with integrity, openness and honesty.

The manager had a good understanding of CQC requirements, in particular, to notify us, and where appropriate the local safeguarding team, of incidents including potential safeguarding issues, disruption to the service and serious injury. We saw evidence of safeguarding incidents being logged and reported as well as safeguarding referrals being made when necessary.

The management team knew people well and were committed in improving the service to ensure people received high quality care. One staff member told us, “[Manager] is doing an amazing job keeping the home running and making the many improvements that was needed”. Another said, “There is a clear focus on person-centred care”.
Staff spoke highly about management and said they were very approachable. Comments included, “[Person] is a lovely manager and easy to talk to”, “Management are always supportive and easy to talk to when you have any issues and always have the door open. They always talk to you and make conversations with you too which definitely makes you feel good, and makes them approachable when you need them” and “[Manager] always goes above and beyond to ensure the home is a happy one”.
 

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 that included details on how to raise concerns, which allowed staff freedom to speak up. Staff feedback was also sought as part of supervisions and staff meetings. Whistleblowing is the act of reporting wrongdoing, misconduct, or illegal activities within an organisation.

Staff felt able to speak up and they felt confident they would be listened to. One staff member said, “I do feel comfortable to talk about anything I’m concerned about”. There was a clear culture based on openness and transparency. People told us they felt able to speak up to the service if needed.
 

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 had an equal opportunities policy in place. Staff had received training in equality, diversity and inclusion to help them understand protected characteristics, bullying and harassment.

Staff felt supported and valued by management. The manager engaged with staff to involve them with running the service. Management ensured equity of opportunity and experience for the workforce within their place of work, and throughout their employment. Staff felt they were treated fairly and with respect.
 

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.

The manager completed a wide range of audits and checks, which monitored the quality of care and celebrated success. However, shortfalls we identified during the assessment in relation to medication had not always been picked up in some of these audits.
Incidents and accidents were recorded and reported by staff. The provider had effective systems to review accidents and incidents, they were scrutinised by the manager and lessons learnt were shared with staff to prevent reoccurrence.
There was evidence of a positive culture and commitment to improvement, and any issues were resolved immediately. During the inspection we found a water risk report completed by the previous provider had not been audited to ensure actions were complete, however, this was immediately actioned. We found no evidence this had a negative impact on people.
There were plans in place for business continuity in case of emergency including extreme weather conditions like heatwaves.
 

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 a good relationship with health and social care professionals to ensure people received consistent, good quality care and support. The management team and staff understood the importance and benefits of working with other professionals.
People’s community participation was encouraged and supported, with staff supporting people to access activities , develop independence and build relationships outside the service.
One staff member told us, “Staff support individuals to engage in hobbies and interests where possible, and there are opportunities for outings and activities". One relative told us, “Since [person] took over as Manager the service does appear to have improved, with far more activities, visits from farm animals, birds of prey etc which is really stimulating for the residents. They have visits from singers and musicians, a toddler and baby group which all help to keep the residents active and stimulated and they just love interacting with the toddlers". Another relative told us, “The numerous activities that are organised for the residents are many and varied, which is a positive indication of the level of care given, in my opinion".
 

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 service actively sought the views of people using the service, their families and carers in developing and evaluating improvement. They had action plans for service improvement with key objectives to strengthen quality and safety, improve outcomes and experiences for people who use the service and support and develop staff.
Comments from the recent completed satisfaction surveys were positive.