The Cumberland

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. We identified a breach of regulation as care records had not always been reviewed or updated and the checks and audits that were in place had not identified the concerns that were found. The previous breaches of regulation had been met, and the provider was no longer in breach of regulation. 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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager promoted an open culture where staff felt confident they could share and discuss their views. The views of staff were sought to improve the service people received. For example, the handover system was changed based on staff feedback. Staff felt they were part of the service with many staff working at the service for a number of years.

The registered manager told us, and observation confirmed there was a homely culture and feel throughout the service where people were treated with kindness and warmth from staff they knew well.

Relatives knew who the registered manager was, and people were observed accessing the registered manager’s office to speak with them during our assessment.

Staff spoke highly of the management team, feeling valued and supported in their role. A member of staff said when speaking about the registered manager and director, “They are very good people. They are very easy to talk to. They are open to hear from us, listen to our problems and concerns about people and how to make things better. They want the home to work well. They want the best care for people, and they value us the staff.”

The registered manager understood their role and responsibilities. They kept their knowledge and skills up to date by completing training courses and being a member of local groups and forums discussing Health and Social Care. There was a senior management team who regularly visited the service and supported the registered manager.

There was an open and positive culture where people, relatives and staff feedback was sought and acted on. Relatives felt confident that action would be taken if required and spoke about examples of changes that had been made based on their feedback.

Staff had been trained and felt confident to ‘whistleblow’ if they needed to. This is the term used when a member of staff reports any concerning information or wrongdoing. Information was also displayed in poster format around the service to encourage everyone about ‘Speaking up’ if they witnessed any inappropriate behaviour.

Staff were encouraged to share their feedback at regular sessions including staff meetings, supervision meetings and annual surveys. Staff told us they found these meetings useful. A staff member said, “It’s a good opportunity to speak in confidence and feel listened to. We are given any updates and thanked for our contributions.”

There was a diverse workforce in place who felt valued as a member of the team and were treated fairly. Staff and leaders had completed equality and diversity training as well as following the providers policy and procedure. Staff told us they felt comfortable working in a team where they were included. Staff felt listened to and knew how to raise concerns or a grievance if they needed to.

The registered manager ensured staff with protected characteristics were supported with any reasonable adjustments if required. For example, shifts had been changed to accommodate working parents with caring responsibilities, additional support had been provided to complete training for staff diagnosed with dyslexia. Breaktimes had been scheduled around times of prayer for staff celebrating certain religious festivals.

There was a clear management structure in place with managers and staff understanding their responsibilities to meet regulatory requirements. Improvements had been made since the last inspection and the registered manager had followed a detailed action plan to ensure the previous breaches of regulation had been met. An annual quality improvement plan was in place which included actions such as, staff development to be enhanced in relation to dementia care courses.

Any accidents, incidents or complaints were fully investigated according to the providers policy and reviewed to see if there were any trends of patterns where improvements were needed. Robust quality monitoring processes were in place. A range of audits were undertaken regularly, for example, health and safety audits, care record audits and medicine audits. The registered manager evaluated all audits enabling them to complete a summary and identify trends and patterns to address any repeated concerns.

Services providing health and social care to people are required to inform CQC of important events that happen in the service. This is so we can check that appropriate actions have been taken. The registered manager had submitted appropriate notifications to CQC.

Relatives told us and records confirmed the staff team worked in collaboration with external health professionals to ensure people remained as healthy as possible. Systems were in place to ensure information was shared to everyone who needed to know as well as the updating of people’s care records.

Staff felt there was open collaboration and support from health care professionals who were accessed when needed. Referrals were made for any additional support when this was required. Staff had opportunities to raise and discuss any concerns they had identified with people they supported and within their role.

There was a culture of learning and continuous improvement to provide a quality service to people. Staff felt that they and other stakeholders were actively involved in shaping and developing the service. The provider developed a ‘Service improvement plan’ which highlighted areas for improvement and how and when the provider planned to achieve them.

The registered manager used regular meetings with staff to discuss incidents and accidents and used these as a learning tool to identity if any changes or additional support was required. For example, following an incident of a person showing signs of distress and in need of mental health support, a referral was made to the Mental Health Team. The team worked alongside staff to implement measures to reduce the risk whilst maintaining everyone’s safety.