Sovereign 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 inspection we rated this key question Requires Improvement and there was a breach of regulation in regards to Good governance. At this inspection the rating has changed to Good this meant the service was consistently managed and well led and the provider was no longer in breach of this regulation.

This service scored 68 (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.

Staff spoke positively about working at the service and felt well supported in their roles.

The registered manager told us about their values which included: people’s needs were met safely, staff were well trained to do their jobs, to be open honest and approachable to people and their families, and to ensure everyone has a great quality of life.

The registered manager confirmed the providers values following our inspection visit. These included person-centred care, choice and independence, and dedicated staff. We did not see how these values were shared to ensure staff were aware of them and the providers expectations in relation to these.

The provider had 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager told us they felt supported in their role and spoke of an inclusive workforce. They told us, “I am very open as a manager. I promote that by going out to support with care needs or will help nurses with a task if they require. I think that helps them to feel they can approach me to do that, and if they are struggling in areas, they will come to me, and I will help where I can.”

Staff told us leaders were visible and gave them support and guidance as well as demonstrating a caring attitude towards them. Staff told us they had regular meetings with management staff and had opportunities to discuss the service and their own development. One staff member told us, “Management always have time for the staff. She [registered manager] is very approachable but is strict if she needs to be, and professional.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People told us they felt confident to speak with staff or the registered manager if they had any concerns. Nobody spoken with had any concerns to share. One person said, “No complaints on how they treat me.” We saw a complaint received had been investigated and responded to in a timely manner.

Staff felt confident to raise any issues or concerns with the management team if needed and were confident action would be taken. One staff member told us, “The manager is very friendly to us.”

Information about policies to support a culture of speaking up such as whistleblowing and complaints were available within the home although most people we spoke with were not aware or did not recall being made aware of a complaints policy.

The registered manager told us, “Recently I have done on supervision what whistleblowing is who to contact and how they would be protected. I also gave them our whistleblowing policy, so they are aware of what they need to do if required to.”

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.

Staff told us they felt included in decisions about the service and spoke positively of the provider.

The registered manager worked closely with staff to ensure there was no bias in everyday practice and to ensure they worked in accordance with the providers policies and procedures. They confirmed they were flexible to staff working arrangements when needed to support staff to carry out their roles effectively.

The provider had policies in place to support equality and diversity in the workplace. Staff had access to these policies on an electronic system.

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.

People were provided with quality surveys to give them the opportunity to comment on the care and service they received. The last survey resulted in 8 responses with positive responses overall. Although some people said they had not completed one, people told us they felt positive about the care and support they received.

Staff understood their roles and responsibilities and were supported through supervision and team meetings.

The provider had governance and auditing procedures to support quality monitoring of the service. Audits included the regular review of medicines, care plans, the environment and accidents and incidents. However, audits had failed to identify issues we had found such as people not being repositioned in a timely manner, issues raised about staffing arrangements and some people not always being left with access to call bells. The area manager visited the home regularly to complete spot checks. The registered manager said, “When she completes audits, she will gather any feedback from that. She will do audits of care plans and reflect back to me. We will speak to relatives and see if anything more they need or require from us.” The area manager usually visited weekly to check that any actions needed were completed.

Following our visit the registered manager advised that plans were in place to action the areas we identified as needing improvement. This included a review of staffing on the ground floor, additional training for agency staff and a lock fitted to a cupboard containing maintenance equipment. This demonstrated the provider took swift action when areas of risk were identified.

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’s needs were assessed prior to moving into the service to ensure the service could meet people’s needs safely. Referrals to health and social care professionals were made when appropriate to manage any risks identified. Records demonstrated improvements in people’s health such cleared infections and healed skin conditions.

Staff understood the importance of sharing information with health professionals to ensure they received the right care to support their health and wellbeing.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice.

Staff completed regular training to support them in their role and in delivering safe care. They felt confident to raise any concerns with management staff and to learn from any mistakes. Staff had regular opportunities to share information with management staff if they saw something they felt needed to be improved. This included during meetings that took place with staff. Each day a ‘flash’ meeting was held where both staff and the registered manager could share information relating to the service. This included any concerns, or areas of learning. One staff member told us, “Everyday at 2.30 there is a meeting to brief everyone on what is going on, on each floor.”

The registered manager told us lessons were learnt when things went wrong. For example, there had been instances when planned care had not been completed within the times stated. They told us the electronic care planning system now used had inbuilt checks to alert staff if planned care had not been given. This gave staff the opportunity to respond to the alert and provide the care needed reducing the risk of ill health.

They also told us following a complaint, a spare call bell was now available on the units so any call bells needing replacement could be replaced immediately if needed.