Sunnymede

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 changed to 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 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive and inclusive culture at the service. People living there, relatives and staff felt it was a good place. Systems were in place to ensure the service was working towards its values and goals. For example, a senior manager said they held a weekly call with the registered manager and discussed key areas such as safeguarding, complaints and staffing.

Staff, people and relatives spoke positively about the service and leaders.

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.

People using the service, staff and relatives spoke positively about the registered manager. Comments from relatives included, “Generally I think the place is wonderful and it comes from the top. Feedback highlighted that the manager and deputy were caring and led by example, creating a positive culture across the service. People told us they felt able to speak with the registered manager whenever they needed.

Staff told us the registered manager was easy to contact and accessible. One staff member said, “I love it, it is like a family, if I have any problems I can speak with any of the leaders.”

The registered manager said the service had designated leads for areas such as dignity and infection prevention and control. This supported staff to follow good practice.

Senior managers regularly carried out reviews and audits for the service and provided support and guidance to the registered manager.

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

The registered manager said they had an open-door policy for staff to come to them with concerns. Staff told us they felt confident speaking with the registered manager if needed. Staff meetings also provided opportunities for staff to feedback and make suggestions for improvements. There were systems for staff to raise concerns anonymously.

Residents’ meetings were held and actions were taken following people’s feedback. For example, changes to the menu.

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.

The registered manager said they had made reasonable adjustments for people. For example, they had made changes to a staff members shift pattern to support their fasting as part of their religion. They also said they had supported a member of staff who had learning needs to complete a care qualification.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on or share key information about risks, performance and outcomes when required.

We found people’s daily care records and records related to health and safety were not easy for staff to access. For example, staff were initially unable to locate one person’s daily care records, although these were found later. The registered manager told us they planned to move to electronic care records, but this had not yet been implemented. In addition, the provider had not always submitted safeguarding notifications to CQC in line with statutory requirements. The registered manager told us they believed CQC would be notified directly by the local authority. This placed people at risk because CQC may not have timely oversight of safeguarding concerns, which is necessary to monitor risks, assess provider responses and take regulatory action where needed.

However, the registered manager regularly completed a range of audits, including checks of care records, the environment, and staff practice. The provider’s internal quality team also audited the service. Where improvements were identified, we saw the registered manager had completed action plans to address these.

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 registered manager told us the service had strong links with the local community. For example, the service has supported local schools by offering work placements, and local church groups had regularly visited the service to provide church services.

Overall, health professionals fed back positively about the service. One professional confirmed the service worked collaboratively with professionals from other organisations.

Leaders also told us they had identified a breakdown in communication with one health partner. At the time of the assessment, they were considering what action to take to improve communication and strengthen the working relationship.

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.

A senior manager said they shared learning from other services. For example, additional checks had been implemented at night to reduce the risk of fire associated with mobile phone chargers following an incident at another service.

The registered manager said they had been involved in healthcare improvement studies in the area including a dental project associated with a nearby dental hospital. The registered manager said this meant all residents were able to have a dental check up in the service if they wanted one.

Leaders said they asked staff whether they needed additional training and explored funding opportunities where possible. Although staff could sometimes experience difficulties accessing external funding, we were told one member of staff had successfully received support to complete and NVQ, which was encouraged and supported by leaders.