Savannah Care Limited

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

This service scored 62 (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.

Staff were supported to deliver person-centred care to people in line with the provider’s values. Staff followed people’s care and support plans which the registered manager made sure were up to date with information about people’s individual needs and preferences. They told us, “I do checks on care and records and this helps me check what is being provided and that staff are doing their job.”

The provider understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

The registered manager was easily accessible and responsive to people and staff. A relative told us, “I have a good relationship with the management. They are easy to get hold of. If I don’t manage to speak to them, I will leave a message, and they aways get back to me. There has been an occasion where I was unwell to support my [family member] and the manager offered more support to my [family member] until I was feeling better.”

The registered manager understood the needs of people and how these should be met through the provision of person-centred care. They were hands on and worked closely with the staff team on a day-to-day basis. Staff told us managers were experienced and supported them in their roles. The registered manager said, “Feedback from [staff] is they are happy with what they are doing.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The registered manager sought people’s views about their experiences of the service through spot checks and telephone monitoring calls. Staff were encouraged and supported to speak up if they had any concerns. The registered manager ensured they were accessible and available to both people using the service and staff to provide feedback or raise concerns. A relative told us, “I do feel I have a good rapport with the manager, and they are supportive and understanding and listen.”

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.

Staff told us they were treated equally and fairly at work. The registered manager made sure all staff were provided equal opportunities to learn, develop and progress in their role.

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, or share this securely with others when appropriate.

We identified serious concerns regarding the registered manager’s understanding of their responsibilities and role, particularly in relation to good governance and the effective management of information. During the assessment, the registered manager did not provide evidence to demonstrate staff received regular training and supervision to support them in their roles. This information was requested on several occasions. However, they were unable to provide this or give a satisfactory explanation as to why these records were not available. This meant we could not be assured effective systems were in place to support and develop staff.

We also found oversight of recruitment procedures was ineffective. Records were not adequately maintained to evidence the information obtained about staff and their suitability for employment. There was no evidence that this information had been audited or checked to ensure it was accurate and complete. This placed people at serious risk of harm, as staff had not been recruited in line with safe recruitment procedures.

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 worked in partnership with health and social care professionals when required. They followed their guidance and recommendations to support staff learning and improve the safety and quality of care and support provided to people. The registered manager told us, “We do listen to advice from the community professionals. For example, the nurses told us how to position people at night to make them more comfortable and reduce risk of deterioration in skin integrity. We talk to the nurses about creams to use.”

The provider could not consistently demonstrate continuous learning, innovation and improvement at the service.

The provider was not consistently using learning to drive improvements. At the last inspection of the service in June 2019, we found improvements were required in relation to record keeping and filing systems to ensure information could be easily accessed. At this assessment, we found these improvements had not been sustained. Staff records were poorly maintained, and the registered manager was unable to locate and provide information when requested.

However, the registered manager sought feedback from people to help improve the quality and safety of the service. We saw examples of changes being made by the service in response.

The provider told us they were planning to move address from their current address, and this change would happen by May 2026. They confirmed they would submit the relevant applications to CQC to request this change. They also told us about future plans to develop the service, including recruiting experienced staff to strengthen management oversight and introducing electronic systems for care planning, staff rostering, medicines management and compliance monitoring.