Silverleigh Cedars

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 outstanding. At this assessment the rating has changed to 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’s management team had the appropriate skills and experience to lead effectively, and they understood the priorities for the service and acted with openness and honesty during this assessment. However, the change of provider had led to concerns and instability at the service. Some staff reported that the rapid pace of change had caused disruption and significant stress for some. The director and management team were supporting the registered manager and had put in place measures to continue to raise standards and improve the culture.

During the transition to the new provider, the registered manager and director had supported the staff team with the changes. We were told some staff were “resistant to change”.

The provider worked in partnership with the local authority and other agencies such as GPs, community specialists and commissioners. This helped to ensure care and support was up to date with current best practice in relation to people’s specific needs.

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.

Overall, people, their relatives and health care professionals felt the service was well managed. Comments included, “The manager is very helpful and easy to get on with. She is visible around the home” and “The manager is delightful. She has respect from the staff and is very attentiveto the residents. We see her around the home regularly”.

The provider had clear systems and processes for their management team to follow, which ensured they had oversight of the service. The provider had a management team who were in place to support the registered manager by completing audits of the service to further improve the care and support people received.

The management team demonstrated throughout the assessment that they were capable, compassionate and inclusive leaders. They were open and transparent with the inspection team. Where risks were identified, immediate action was taken to address the issue.

The provider fostered a positive culture where most people felt they could speak up and their voice would be heard.The provider had several channels available to staff, relatives and people living at the service to share any suggestions or concerns they had.People and most relatives told us the management team were approachable, and they felt able to contribute their thoughts and suggestions or raise any concerns. Most were confident any issue raised would be addressed. Comments included, “They are very open to suggestions” and “They ask for feedback…We can always talk directly to them”. However, one family member was less confident and said they had raised issues or suggestions but “nothing changes”.

The provider had a whistle-blowing policy which was accessible to staff, along with a confidential helpline to report any concerns. Staff were aware of how to arise any concerns; however, some staff felt their concerns about staff allocation and work pressures may not be listened to or acted on. The director and registered manager acknowledged recent operational changes had affected morale and they were actively working to improve transparency and rebuild trust within the staff team.

The provider valued diversity in their workforce. They were working towards an inclusive and fair culture by improving equality and equity for people who worked for them.The staff team was diverse with many staff from overseas. The provider’s recruitment procedure helped ensure equality of opportunity for applicants.Some staff reported low morale and limited psychological safety, some felt there was favouritism which impacted on things like leave or shifts requests. As a result, not all staff felt valued, respected, or supported in their roles.

The management team were taking additional steps to strengthen equality and inclusion. The director had been reviewing workplace culture, looking at promoting staff well being initiatives, and encouraging open dialogue to ensure all staff felt respected and included.

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.

Systems to monitor performance, risks, and outcomes were in place. The provider had systems to oversee and ensure the quality of care. The management team (registered manager, director and provider) had established a range of quality audits, digital records, and action plans. These were reviewed regularly and updated. They were keen to learn and improve by analysing incidents/accidents, feedback, complaints and concerns.

The provider had a comprehensive service improvement plan, where actions were added and monitored to ensure they were completed. The management team acted on information promptly to address areas for improvement, including environmental and safety matters.

The service was well supported by the management structures in place. The registered manager was supported by a deputy manager and the provider’s senior management team, including a director. There was always a nurse and senior member of staff on duty and a senior member of the management team on call should additional support be required out of hours. Staff were aware of their roles and responsibilities.

The management team understood their responsibilities in relation to their regulatory requirements around notifiable incidents. Notifications were shared appropriately with external organisations, and lessons learned from audits and incidents were acted on to enhance service quality. This approach ensured that people received care that was safe.

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 provider had good working relationships with external health and social care professionals.

Care plans clearly showed that staff listened to advice from doctors and other health professionals. One professional said, “I find it a pleasure to visit Silverleigh care home”. Working collaboratively supported people to achieve positive outcomes in relation to their health and overall well being.

Relatives felt sure their family member could see a GP or specialist whenever they needed to. Staff also helped people book and attend their health and social care appointments.

People were supported to attend external clubs and activities within the local community. These community connections helped people to maintain links with other people with similar experience and interests.

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 promoted learning and development, through their governance systems, regular feedback from people and relatives, and regular reviews of people’s individual needs and risks.

A structured improvement plan was also in place, demonstrating that leadership maintained thorough oversight of service quality. This system ensured that necessary improvements were clearly identified and that all remedial actions were accurately documented.

The provider and registered manager had oversight of accidents and incidents. Trends and patterns were identified and addressed.Where risks of people leaving the care home without support had been identified, the provider had implemented The Herbert Protocol. This is a national scheme designed to assist in locating individuals with dementia who may go missing, providing essential information to emergency services for a swift response.

Following the findings at this assessment, action was taken promptly to address the shortfalls identified. For example, changes were made to mealtimes to ensure people had the support their required and where meals were declined.