The Devonshire Also known as 1- 3883899011

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 remains good. This meant people were safe and protected from avoidable harm.

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

This service scored 64 (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. 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.

The provider had a clearly defined set of organisational values that were embedded within staff practice. Audits showed staff were regularly reminded of these values, and spot checks confirmed staff were able to describe them appropriately. The organisational values were also included in appraisals.

The registered manager spoke positively about the provider’s shared direction; they told us they felt able to raise concerns with senior management and were listened to. They told us they felt the provider was changing in a positive direction, in line with the organisational values.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

We received mixed feedback from staff about the management of the home. One staff member told us, “[Manager’s] door is always open to everyone, to anyone who feels a need to make a complaint or suggestion. [Manager] gives us guidance and feedback.” Another staff member told us, “The [registered manager] is not approachable most of the time. There is not an open door policy, most days. I feel they do not want to listen most of the time to concerns and I feel there is no point as it gets ignored.”

Most people and their relatives were not aware of who the registered manager was. One relative told us, “I have no idea who the manager is, nor indeed where I would find them.” This lack of visibility meant effective leadership was not always evident to people or their relatives. As a result, the provider’s stated values of integrity and inclusion were not consistently embedded in day-to-day practice, limiting opportunities for people and relatives to feel engaged, informed and confident in the service’s leadership.

The provider fostered a positive culture where people felt they could speak up.

Most staff told us they felt able to raise concerns with the registered manager, or other members of the management team. One staff member told us, “We have different people to reach out to, we have the line manager, clinical lead and if I have any issues I prefer to reach out to my immediate manager before going to the registered manager.” However, further work was needed to ensure staff felt listened to when they raised concerns.

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 celebrated and championed their diverse workforce. The provider employed staff from the local area as well as from overseas. The staff team were from varied backgrounds and cultures, and this was reflected in the skills and experience they brought to their roles.

The registered manager spoke very passionately about staff inclusion and how it was important for all staff to feel included and valued. Records showed equality, diversity and inclusion had been discussed in team meetings, and staff regularly completed equality and diversity training.

One staff member told us, “[registered manager] is always opening [their] door to everyone, there is a respect to everyone, there is equality for everyone.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

The registered manager and provider monitored the quality and safety of care provision through various audits.However, actions were not always identified or followed up. For example, the provider’s health and safety audit did not always identify safety issues with fire doors or the environment. In addition, the provider did not always act in line with fire recommendations to ensure identified risks were promptly addressed.

The provider completed a weekly call bell analysis audit, which identified call bells were not always responded to within 5 minutes, in line with the provider’s policy. However, the provider failed to investigate the delays and act to prevent a recurrence. The action for most of the call bell analysis audits said the same thing, which was staff had been informed.

The provider had a system in place to monitor and audit people’s medicines on a regular basis, however there were discrepancies in the recording of this, which had not been identified by the provider’s audit. For example, for 2 people who had their medicines covertly, their next of kin and registered manager had not signed to authorise this. However, people had received their medicines correctly.

People and their relatives consistently told us they didn’t know who the registered manager was. It had been highlighted in the provider’s audits that people did not know who the registered manger was, however, the provider did not identify any actions required, as the reason for this was put down to people living with dementia.

Some audits had been used effectively and identified shortfalls around care planning and people’s dining experience. The provider had taken action to improve these, for example how lunch was served.

The provider responded proactively to our feedback and planned to use our feedback to drive improvement.

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.

We received positive feedback from stakeholders who told us the provider worked well with other services and gave positive feedback on the provider’s communication.

The provider encouraged the local community to visit the home;, they held activities such as an arts and crafts group which members of the local community attended. Local school children visited the home and spent time socialising with people. An external organisation attended regularly and held coffee mornings and a sing a long session.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

A culture of continuous learning was not consistently embedded across the home. Opportunities to share learning from incidents and use this to improve care quality were not fully supported throughout the staff team.

The provider had action plans in place to help drive improvement of the home, and the management team spoke positively about improving outcomes for people living in the home. However, not all actions were followed up.