Estherene 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 Good. At this assessment the rating has changed to Requires Improvement. Further improvements were needed to ensure governance systems were sufficiently robust and staff culture was monitored.

The provider was in breach of the legal regulation relating to good governance.
 

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

During this assessment, we identified breaches of the legal regulations. This meant the management team had not always identified and taken action to ensure people received care that was in line with legal requirements. The registered manager and provider were not aware of examples of poor culture which had a detrimental impact on some staff working at the service. Once they became aware they took steps to open communication and improve conditions for staff. The provider had been more active in the service recently, due to the staffing concerns, and the registered manager told us they felt supported by them. Low staffing levels in the service seemed a common theme among staff feedback. There was not a pool of staff available to the provider to call on in the event of sickness and therefore often shifts could not be covered. Agency staff were not considered to fill the gap in the interim, having determined how many staff were required to keep people safe. Staff told us they thought the registered manager was mostly accessible, but some did not always feel listened to. Staff thought the registered manager was aware of any service issues and would often be seen ‘on the floor’ speaking with people. One staff member said, “They [registered manager] are good, but sometimes I think their hands are tied to an extent where improvements are concerned.” Another staff member said, “I think [registered manager] is starting to listen, my ideas are being put into place now.” Relatives we spoke with knew who the registered manager was. One told us, “I do know [registered manager]. I think she is very good, she is accessible, and she is business like, she tells it how it is. From what I’ve seen she has leadership to run a good ship.” The registered manager was able to tell us plans they had to develop systems to enhance people’s care, and we saw they put these ideas to the provider for consideration. The provider demonstrated that they understood how to make improvements in the service, however some actions had not always been effective in mitigating risk. The provider had plans to enhance falls analysis within the service, and shared information with us about how this would look in practice . Reasonable adjustments had been made for people whose mobility had reduced, or if they had been experiencing falls. For example, their rooms were moved to the ground floor. The majority of relatives we spoke with confirmed they were involved in their [relatives] care plan.

There were processes in place to encourage staff to share concerns and speak up. However, some staff had not always felt able to do so, so they shared their concerns externally with CQC. Staff told us they did not feel sufficiently empowered to raise concerns directly with the provider or registered manager. The provider in response to the concerns, held staff forums and 1-1 meetings with every staff member. They also discussed whistleblowing procedures and how staff should utilise this if needed. Most staff told us that the registered manager was approachable and supportive but sometimes they did not always feel valued in their role. One staff member said, “I don’t always feel valued. I’m very tired from the workload, and the ‘employee of the month’ scheme can sometimes be quite random.” Another said, “They [registered provider and manager] do their best I think, and we do speak up in meetings about things we might be concerned about. Sometimes changes happen, but not always.” Enhanced contact with night staff was in progress to ensure they did not feel isolated, and any issues were identified promptly.Staff surveys were also carried out annually. This gave the provider staff’s views of working in the service.

The systems in place to check on the culture at the service had not always been effective. Following CQC alerting the provider of potential staff conduct concerns, they met with staff and were able to confirm there were issues they had not previously been aware of. They took steps to resolve the issues, however, staff had not felt empowered to report their concerns internally to the registered manager or provider. The provider had not ensured staff understood about equality, diversity and human rights. Some staff had experienced discrimination from others. We discussed this with the management team who investigated staff concerns and took appropriate action. This included, discussing the situation in staff meetings and working with staff to look at how they could improve the experience for the workforce.
We asked staff if they felt the service was well-led. Mostly staff felt the service was well led by the registered manager, but they did not always feel valued. One staff member said, “[Registered manager] is doing her best, but their hands are tied.” Another said, “I’ve never had a 1-1 meeting with the manager, only the senior staff. I’d like to meet with the manager and get to know them. At present I don’t feel valued.”
Most people living in the service spoke positively about the registered manager and knew who they were. However, 1 person told us they had witnessed disagreements between the management team and they felt this was not appropriate.

The provider’s governance systems were not always fully effective. Systems had failed to ensure concerns were identified and action was taken for example, unsecured medicines and improvements needed with medicines documentation. People's capacity to make decisions related to their care and treatment had not always been considered fully. Record keeping in relation to this showed a lack of understanding in relation to the Mental Capacity Act 2005 (MCA) and the service had not always acted in accordance with the MCA. For example, mental capacity assessments in relation to people’s care were not always ‘decision specific’ as they held multiple decisions about their day to day care needs, such as medicines, sensor mats (which alert staff if people are attempting to walk) and nutrition. They also included some restrictions such as lap belts on wheelchairs. Decisions such as these should be assessed separately so it is clear that the least restrictive decision has been made in people’s best interests. Care records did not always make clear what decisions people could make for themselves. For example, decisions about meals or drinks, or what to wear, and therefore did not place focus on encouraging independent decision making even at a basic level. In practice, people confirmed that staff respected their wishes and always asked if people wanted support before proceeding.

Governance systems needed to be more robust to ensure people’s care needs were flagged to external professionals in a timely manner. Care plans did not always contain detailed information about people’s individual needs, for example, where people were living with dementia. The registered manager had already begun work on improving care plans and had allocated senior staff to undertake this work. Some people’s care plans were inaccurate or had missing information. The current lack of accurate or detailed information in people’s plans meant the provider could not be assured that people were always receiving the most appropriate care. Care plans were not of a consistent quality, for example, some but not all care plans were contemporaneous and contained good and detailed information for staff.

Governance in relation to staff culture needed to be more robust to ensure concerns around staff conduct do not re-occur. The provider confirmed there will be increased monitoring and support for night staff.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team told us they undertook lessons learned where shortfalls had been identified. They were working on an improvement plan and told us they were committed to make the necessary improvements in the service. They explained that they understood improvements were needed in the service; however, these were not all yet fully implemented.
The registered manager had not always identified where improvements were needed, but they had been responsive both during and after the assessment. They were able to tell us about future improvements that would benefit people’s quality of life, such as implementing assistive technology that would support the reduction of falls in the service and requested that the provider considered funding this. The registered manager had introduced workplace ‘champions’ in the service (staff with additional knowledge who share best practice) in relation to nutrition, infection control, oral health and other relevant areas, to improve practice. The registered manager looked to widen training to enhance staff skills. There was a staff reward scheme in place, and ‘Employee of the month’, which we saw was displayed in the service.