Daleside Nursing 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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 did not have a clear shared vision, strategy and culture. Some staff were not all able to tell us about what the provider’s overall vision for the service or values were although staff positively about working for the provider. One staff member commented, “We work as a team, everyone works together, feels like a family. It feels relaxed here and we do spend time with the residents.” The provider’s vision, strategy and culture were shared on the providers website and within literature about the home. However, feedback from some people, and their families demonstrated they were not all confident the provider had yet made all the necessary improvements following our last assessment. Examples of this have been reported through this this assessment report and were shared with the provider. The provider recognised further work was needed to rebuild trust and confidence with some people and their families to embed a positive and consistent culture.

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. Since our last assessment the management team had changed. Staff told us they felt well supported and leaders were approachable. A staff member told us, “The office and company are approachable, and I can talk to them anytime. They respond well to emails.” The provider was responsive to the feedback we shared throughout the assessment and took action to address any shortfalls we identified.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had policies and procedures in place which guided staff through the process to speak up. Staff told us they felt confident to speak with the new management team and felt they would be supported through this process.

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. Policies and procedures were in place to ensure people were treated fairly and equitably. This included when staff had protected characteristics under the Equality Act 2010.

The provider had made improvements to governance systems since the last inspection. Most of the shortfalls we identified were already known to the management team which informed an ongoing improvement plan. Some actions were still being worked upon, and some actions had been signed off as completed but we found this had not led to sustained improvements as we found evidence of similar issues reoccurring. For example, shortfalls in the cleanliness of some equipment in the home. Some aspects of medicines management monitoring systems also needed further focus to ensure records were updated and introduced without delay following a person being newly admitted to the home or a change in people’s needs.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The manager worked closely with other professionals. Partners who worked with the service told us partnership working had improved. However, some family members told us they did not always feel engaged in the planning of people’s care or well informed when there was a change in the person’s needs. For example, a family member described a recent injury a person had sustained and told us they only became aware when they visited.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Since our last assessment there had been a change in the management team. Systems to engage with people had been recently re-introduced, including family and resident meetings however, these needed more time to become embedded and to encourage people to fully engage. The provider had displayed actions they had taken in response to recent feedback on a ‘You said, we did’ board. Records were maintained of any complaints received.