Shottermill House

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 remained 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.

The provider had a shared vision, strategy and culture. People and their relatives told us the culture of the home was welcoming, caring and respecting people as individuals. The provider’s values of transparency, compassion, community and excellence were reflected in the way staff supported people and in their operational plans for the home. The provider aimed to meet people’s needs physically, spiritually and emotionally with ‘fulfilled lives’ ethos for people and staff on the forefront of their approach. The staff and management team we spoke with supported this ethos in their roles. A relative said, “Shottermill is the best place. I would highly recommend it to anybody - good care and food, friendly and helpful staff.” The provider had clear expectations towards staff’s values and conduct, called ‘the way we care’. These were discussed regularly with staff and formed part of their job roles. The registered manager monitored staff’s practice to ensure all staff were showing these values in their day-to-day work. People, their relatives and staff told us the management team were leading by example in their approach which was caring, kind, compassionate and attentive. For example, a relative told us how the business manager had a habit of seeing all staff and people before they ended their working day to ask how they were and to have a short chat with everyone.

The provider had inclusive leaders 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 and their relatives, as well as staff we spoke with, were all very complimentary about the leadership in the home. A person commented, “I get on very well with the manager, she is the best and will do anything for you and the senior staff are good, and all the [staff] are very caring and kind.” A relative said, “That’s the real strength (here) – the energy and personality (of the leaders).” Another relative told us, “[The home] is very well-led, I cannot tell you how efficient [leaders are]. [The business manager] is superb and [the registered manager] is very helpful.” A third relative said, “It is a very caring environment, [managers] are available. They are very communicative; they listen and give the right advice when needed.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt comfortable approaching the management to raise any issues, suggestions or concerns. Safeguarding and speaking up was discussed during staff meetings.

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. A staff member said, ”I love it - the home and my role. I don’t go home stressed. It is nice to actually have a good day at work.” Staff told us they felt supported, valued and respected in their roles. Adjustments were made to staff working patterns and roles where needed because of staff’s family, personal or health related matters. All staff were included in the running of the home and encouraged to get involved in staff meetings and to provide feedback.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The management team had clear areas of responsibility in relation to monitoring quality and safety of the service. A range of audits were completed, including for example, management walk abouts, night spot checks, care records audits, maintenance and health and safety checks, infection prevention and control, food safety audits. The provider supported the management team in overseeing the home and completed provider audits of different areas of the service. Where improvement needs were identified, we saw evidence of actions being taken to implement positive changes. However, the audits and checks did not always identify all discrepancies and gaps in people’s care planning, daily care, behavioural monitoring and ‘when required’ medicines records and guidance. The registered manager took immediate action to clarify and improve the recording in the home. They provided additional information following our site visit to clarify any shortfalls and identified actions required to improve recording. People’s safety and wellbeing were not affected as staff supporting people were consistent, knew people well and the care was well coordinated with the management being regularly updated and acting on any changes in people’s needs.

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. People, their relatives, volunteers and staff told us the home worked well with a range of community organisations, health and social care services and the local community members. A healthcare professional working with the service said, “I found [the registered manager] and her staff to be professional, approachable, and responsive. They demonstrated good engagement, adhered to all necessary procedures and documentation, and appeared to have a positive working relationship with one another.”

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. The management team had clear action plans in place and priorities for development and monitoring of the service. A range of actions were taken to improve people’s safety and experiences of care. For example, the registered manager acted on trends and themes identified in their review of incidents and accidents and addressed root causes. The management team followed fire safety advice and took action to remedy any safety issues identified. This mitigated risks to people’s safety. The immediate service level actions were also logged within an action log, allocated to responsible staff and monitored for completion.