The Shrubbery

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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

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. The service was in breach of a legal regulation in relation to good governance.

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 always have a culture that supported people to be as independent as they could be and allow them autonomy in all aspects of their lives. Staff told us the culture of the service focused on the wellbeing and safety of people living in the home. However, routines in place to support people to get up in the morning were in place to suit the staff’s routine rather than people’s choice. People consistently complained about a lack of activities that met their preferences. People we spoke to, told us they liked the registered manager. One person told us, “I know who the manager is, and they are very approachable.’’ One staff member said, “The staff team are good, we work well as a team. We all focus on the residents making sure they are safe and happy.” The registered manager told us, ‘’We share ideas and have an open-door policy. We share information in staff meetings or supervisions.’’ Following a review of incident records, incident forms recorded that the relevant action and referrals had been completed following any incidents.

Not all leaders understood the context in developing a culture of person-centred care. Routines had been put in place to support staff to be able to deliver care, but these routines did not always support people’s rights. For example, waking people early and a lack of stimulation and activity. These routines did not support a caring and compassionate home environment for people. We could not be sure the provider was capable as they failed to identify and address the concerns we identified in our assessment, such as issues with medicines and care plans.

People and the staff told us that the registered manager was caring and approachable. One staff member said, “The registered manager is approachable.’’One relative told us, “The manager is friendly and is a good manager. The home is well run and I’m very happy with the home.” The registered manager was proactive to all feedback raised during this assessment. We discussed their duty of candour; the registered manager understood their duty to always be open and honest.We discussed social interactions, and the registered manager acknowledged that improvements were needed to promote social engagement and daily activities within the service. Statutory notifications were raised with us in accordance with the provider’s duties and responsibilities. Notifications are events providers are required to tell us about, such as allegations of abuse, serious injuries and deaths.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt confident to speak up against any poor practice or raise concerns. One staff member said, “I’m confident enough to raise an issue with my manager.” A whistle-blowing policy was in place and staff told us where they could access it.

The provider valued diversity in the workforce. Staff told us they were treated fairly by the provider. Staff told us there were opportunities for further development and when they experienced personal issues which impacted upon their working ability, the provider was supportive and made allowances. Minutes of team meetings and supervisions evidenced staff were included to feedback into the service. Staff received equality and diversity training.

The provider had an appropriate equality, diversity and inclusion policy in place to ensure that all individuals are treated fairly and with respect, regardless of their background or characteristics, and to prevent discrimination and promote inclusion.

The provider did not always have robust systems or auditing processes to ensure good governance. The provider’s governance systems had not identified the concerns we found in relation to infection control and medicines. The failure to identify concerns around infection control and medicines management could directly compromise the health and safety of individuals receiving care. The governance systems hadn’t picked up on people’s dissatisfaction with a lack of activities, the food, and routines, all of which were essential to quality of life. This demonstrated a disconnect between leadership and the lived experience of those using the service. The registered manager was open and receptive to our feedback and assured us that new systems and processes would be put in place for all areas of concern identified. We will assess the success of these new systems in our next assessment. Staff told us they were regularly checked for their competencies, and they said they believed in the registered manager’s ability to lead.

The provider understood their duty to collaborate and work in partnership. They shared information and sought advice when needed. People told us they felt included in the service.

Relatives told us the provider worked in partnership with other professionals such as chiropodist, district nurses and other healthcare partnerships. Staff told us they worked with other professionals, and they worked effectively a team. One staff member said, "We are a good team, and we support each other.” A professional told us the registered manager worked effectively in partnership and shared information openly. Records confirmed the provider worked in partnership with other professionals and raised referrals promptly.

The provider did not always focus on learning, innovation and improvement across the organisation. Staff told us lessons learnt from incidents and accidents were shared during handovers and team meetings. One staff member said, “When we talk in staff meetings all our opinions are listened to by management.” Lessons learnt from accident, incidents and complaints were reviewed and shared with the staff team. However, reflective practice was not always consistent for staff to learn from incidents or accidents when things went wrong to ensure continuous learning was understood. The provider had failed to identify several shortfalls within the service so we could not be sure areas of improvement and learning would always be identified and addressed.