Archived: Squires Mews 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 Squires Mews Care Home since it was registered. 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 and staff understood the provider’s vision and values to provide good quality care, supported by strategy and underpinned with policies and procedures. There was an open, transparent and inclusive culture to continuously improve the quality of care, ensuring people remained at the heart, and management were responsive to feedback.

The provider promoted a culture that valued reflective learning and improvement. Effective communication systems and processes ensured information was shared with staff promptly. For example, daily handovers, staff meetings and alerts when updated were added to people’s electronic care records. We observed management treated people and staff with dignity and respect. Management had daily meetings with heads of departments and key information was communicated with the staff team. The registered manager held individual and group meetings which provided a forum for staff to raise any concerns and share their views and ideas.

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 provider and registered manager were experienced, skilled, knowledgeable, and were committed to providing a welcoming care home. There was a clear management structure that ensured staff had effective support and guidance at all times. The registered manager understood their legal responsibilities, and kept up to date with relevant changes and notified CQC as required by law. The provider maintained oversight of the care home with regular visits, audits and accessing the electronic system remotely. There were processes to support the registered manager and senior staff in meeting their responsibilities.

People and the majority of relatives we spoke with were positive about the leadership and the management of the service. The registered manager had been responsive to feedback during this visit and action was taken. Staff spoke positively about the management team and their approach which focused on providing quality care. Staff comments included, “Manager and seniors are approachable” and “We work together to make sure everything runs smoothly, residents are safe and their needs are met, and ensure clinical care is managed well.”

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

People and their relatives were provided suitable opportunity to speak up, for instance, during care reviews and individual meetings. Staff also have a range of opportunities to speak up for instance, supervisions and staff meetings. Staff were aware of the provider’s policies that supported them to raise any issues relating to poor practice, concerns and complaints such as whistleblowing procedures and ‘speaking up’. Staff told us they felt confident if they used these procedures, they would be listened to, and management would act on concerns. The registered manager told us they operated an ‘open door’ policy and welcomed all feedback. Management meeting records confirmed actions taken to concerns raised by staff.

The registered manager and staff were also positive about the provider and the approach of the director of operations who they described as ‘engaging and supportive’. A member of staff told us, “[Name] the director visits regularly and they always speaks with staff to find out how things are.”

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 policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. The registered manager understood their responsibilities in line with the Equality Act 2010 and its implications for employees. For example, recognised and supported staff when they needed additional support with training.

Staff confirmed they were being treated fairly and equally with regards to their protected characteristics and felt valued and supported. Staff were positive about working for the provider and team working. Staff wellbeing was promoted, for instance flexible working patterns and privacy to observe their faith.

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.

The provider had oversight systems and processes in place to assess and monitor all aspects of safety and quality of the service. These included audits, and checks to monitor if people were treated with kindness, compassion and received safe care. We checked a sample of the completed audits, and where issues had been identified action was taken and improvements were monitored to ensure they remained effective. However, some issues we found during this assessment had not been identified through the provider visits, daily manager walk-arounds or in the previous audits carried out. For example, cleanliness of kitchen equipment and completing medicine records fully in relation to ‘as required’ medicines administered. Action was taken when these issues were raised with the registered manager. The registered manager assured us these areas would be strengthened and monitored to prevent recurrence.

The registered manager ensured the management team was visible within the care home and available when needed. The management team member told us, “We hold clinical meetings every Friday. It’s a time to review residents’ needs, any health changes, wound care, falls, and ensure we’re following best practices” and “I supervise staff practice, check their competency regularly, and provide guidance.”

The provider representative and the management team completed a range of audits and observations. The electronic care system used meant the provider could access reports on the safety and quality of people’s care to maintain effective oversight. For example, care plan reviews and analysis of accidents, incidents and complaints. The provider’s contingency plan in the event of an emergency and for evacuation of the care home was kept up to date and reviewed regularly.

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 registered manager and staff worked closely with a variety of health and social care professionals to ensure people’s individual care and support needs were known, understood and met by staff. People’s care records confirmed referrals were made to health professionals when required and instructions given had been followed. This demonstrated collaborative approach care.

There were links developed with local community groups and promoted inter-generational activity. A relative said, “[Person] is fully independent and walks around the garden every day and they joined the gardening club. [Person] does the activities and sometimes staff take them to Morrisons so [Person] can get some bits. It’s a massive improvement for [Person].”

The local authority responsible for some people’s care and health professionals told us management and staff had worked collaboratively. They told us when issues and concerns had arisen the director of operations and the registered manager had been open, transparent and responsive to ensure people remained safe.

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 provider’s policies and practices were underpinned by best practice guidance. The provider, management and staff recognised the importance of learning lessons from accidents, incidents, audits and feedback, as an opportunity to improve the service and people’s quality of life. Reflective practice was used effectively, and learning was shared with staff. The registered manager and staff were responsive to feedback and addressed concerns raised during the on-site visit. A member of the management team told us, “I review and guide care planning, especially for people with complex needs or where nursing input is required. I also help senior staff update risk assessments when there are changes.”

The registered manager kept their knowledge and skills up to date. The provider’s internal forums and local authority meetings supported the sharing and learning of best practices.

Feedback received from health professionals and the local authority as part of this assessment confirmed the management and staff worked with them to continuously to provide quality care. The local authority’s latest quality monitoring visit was positive and no actions were required.