Archived: Vale Court Care Home

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• 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 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 care.

The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 54 (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 always have a shared vision, strategy and culture with their staff team. 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. We found staff meetings were infrequent and did not evidence information sharing of strategic planning and goals and did not evidence this was communicated with staff.

The provider did not always have 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. However, the provider could not demonstrate robust induction, some elements of training and competencies were not checked, development and supervision was not available for all staff. The provider could not demonstrate there was a governance process assessing the culture of the service and the quality of care being delivered regularly.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The staff we spoke with felt they could openly speak up about any matter and told us they were confident with the whistleblowing processes and how to raise issues. However, staff we spoke with did not know what the freedom to speak up process was and were not aware of a speak up guardian process which can be supported in services.

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 provider supported staff sponsorship schemes and staff we spoke with felt supported and valued in their role.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance in relation to governance meetings frequency, audit completion and audit oversight.

Duplication of processes in the service in paper-based format and electronic format demonstrated hard copies were viewed as incomplete, management sign off not in place on documentation or actions completed had not been checked for completeness.

Staff meetings were infrequent; staff were not in receipt of regular supervisions and annual appraisals for all staff were not in place and did not support staff development.

Staff induction was not always robust, safe staffing processes regarding agency usage was not always effective and oversight of staff training compliance was ineffective.

IPC audits and daily walk around processes and care plan audits were not always effective to pick up the issues we found at this assessment.

The governance system in the service was improved from the last inspection, breaches from the last inspection were checked for compliance, however, there are further improvements to be made from this assessment process and there was a continued breach of regulation 17, good governance.

Feedback from staff and family members regarding the management of the service was all positive, staff felt the managers door was always open, and the manager was approachable and supportive.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement. Feedback from partners was positive in relation to collaboration and partnership working.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system due to the issues described in this report. There was a lack of robust quality assurance systems in place to evidence continuous improvement and a consistent approach to measuring the impact of change. However, the provider was slowly moving from paper-based systems to electronic based systems. The provider did recognise staff achievements and contributions and provided a recognition scheme.