Conifers 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

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.

The service was in breach of legal regulation in relation to governance at the service. Management processes had not always identified issues we found during our inspection.

This service scored 57 (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 which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. Staff and leaders could not explain what the provider’s values were and therefore were not part of a shared culture. However, 1 staff member said, “Everyone at Conifers is caring and would go out of their way for the people living there.” Another staff member said, “I don’t know what the values are.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. People, relatives and visiting professionals had confidence in the registered manager, however staff and leaders needed to improve to ensure issues were identified and quality audit systems implemented effectively and embedded in to practice.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and leaders had access to a whistle blowing policy and staff told us they felt able to raise concerns. One staff member said, “I am very confident my manager would take the appropriate actions if I were to whistle blow. If this wasn’t the case, then I would escalate the issue and contact the safeguarding team and CQC. If there were immediate danger, I would contact the police on 999.” However, some staff felt their views were not always listened to. We raised this with the registered manager who told us they would improve systems and processes.

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 regarding equality and diversity, and staff were supported to work in line with them. The management team told us they listened to staff and operated flexible working arrangements wherever they could. Systems were in place to support staff out of office hours and at weekends. Members of the management team were on call to support staff if required.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. The management team did not have a good overview or insight of the service. Audits in place did not identify concerns we found during our assessment in relation to safe care and treatment, medicines management, IPC and good governance.For example, prior to our inspection there was no stock control system in place for medicines, which meant the provider had no record of medicine stock on site. The infection control audit had not identified the issues we found, and the care plan audit and review process had not identified the concerns we found in relation to management of risk. These issues were addressed by the registered manager after our inspection; however, new processes needed to be embedded in to practice to show they were effective.

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. Partners were complimentary about the way staff and leaders worked alongside them. One professional said, “When visiting the care home, I find the staff always courteous and professional. There appears to be good organisation and leadership in the home. The lead nurse is always aware of the reason for the visit and has relevant information to hand.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. At our last inspection the service was rated good, however, at this inspection the service had changed to requires improvement. The service showed signs of deterioration and a lack of learning had taken place. For example, accidents and incidents were recorded but not always analysed to ensure trends and patterns were identified to mitigate future risks.