55 Sandwich Road

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 remained 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 clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. There was a clear vision at the service which focused on actively seeking and taking opportunities to promote people’s independence and quality of life. People were able to exercise maximum choice over their daily lives and were supported by a staff team who empowered them to take positive risks. For example, people might become distressed by visiting new locations or trying new activities, so staff would often take people for an informal visit beforehand to allow them opportunity to explore this in a safe and accessible way. This allowed people opportunity to discover meaningful and positive activities that promoted their quality of life.

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.

There had recently been a change of management, with the current registered manager and deputy manager dividing their time between this service and another nearby care home. They were able to do so effectively in response to the needs of each service, and staff spoke highly of the positive impact the new registered manager had made on the service. Leaders were knowledgeable about people’s needs and led a culture that promoted individuals independence and wellbeing. They demonstrated integrity and had a clear vision for the service which focused on ongoing quality improvement. They led a team that were happy and felt trusted and empowered. One staff member told us, “At the moment things really good, and I’m happy here. The registered manager really cares and listens. Our team get on really well and everybody cares. We now have a much stronger focus on activities. Management are always supportive of new ideas and trust staff.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistleblowing policy in place at the service which staff were knowledgeable about and expressed confidence in wherever they chose to raise concerns that these would be listened to and acted upon. There were a number of different routes for staff to raise concerns including informal conversation, supervisions, team meetings, and to senior management within the service. For example, one member of staff explained they could raise concerns with the area operations manager if they didn’t feel comfortable speaking to their own manager.

The provider valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

The provider cared deeply about their staff, and staff spoke of a culture where they were supported at all stages to balance their own personal circumstances with working life in a way that was sensitive and personalised. For example, staff told us they never had to worry about taking leave for personal health appointments for childcare, and that their team worked collaboratively to support each other. One member of staff told us, “Our manager puts staff and people first. Any time you need help she is always there. She’s perfect and lets you have balance between home and work. We are very happy and safe working here.” The provider conducted regular surveys of staff experience to identify areas where they could make improvements. They had also recently set up a REACH (Race, Ethnicity and Cultural Heritage) mentoring programme shaped by people from minority background. This was designed specifically to support people more likely to face barriers and discrimination in progressing within their adult social care career.

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.

There were robust governance systems in place to monitor the quality and effectiveness of the care being provided at Sandwich Road. This included regular audits of care documentation and incidents and accidents to ensure that people’s care continued to meet their needs. There were routine checks on staff knowledge and competency, management of medication and the safety of the environment. These were largely effective and had identified areas for improvement which were monitored through a service improvement plan. In a small number of areas, they had not identified concerns raised by the inspection, but leaders responded proactively where these were raised. There was a comprehensive business continuity plan which set out how the service would continue to provide care safely in case of a significant event, such as a failure of a utility, staffing shortages or an adverse weather event.

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 were clear systems in place of how the provider would work with key partners in response to people’s changing needs, and detailed guidance setting out at what point referrals to partners may need to be made. We saw referrals had been made proactively and there had been recent involvement with mental health and occupational therapy teams to ensure people were being supported safely. The registered manager actively participated in local networks to share best practice to drive ongoing quality improvement. Partners spoke positively of the collaborative relationships they had developed with the service. One stakeholder told us, “We work well with the registered manager and indeed the rest of the area management team, they are transparent and communicative and liaise with us proactively in respect of clients and any service-identified issues.”

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.

There was a commitment to ongoing learning and quality improvement within the service. There was a service improvement plan which set out clear actions and timescales to continually improve the quality of care being provided. Incidents and accidents were proactively analysed, with opportunities for learning regularly shared with staff through team meetings and briefings. This included learning from within the wider organisation, and a briefing had recently taken place following a choking incident at another service. As a result of this, focused work had taken place for staff on how they should respond to choking incidents. Checks of choking rescue tools at all services operated by the provider were undertaken to ensure these were accessible at all times, and staff knew how to use them.