Saffrons Care Home

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. At this assessment the rating has remained the same.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the regulation relating to governance.

This service scored 61 (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 and strategy, but improvement was required to ensure that person-centred practices were embedded throughout the service. The registered manager told us that the key values of the service were to provide family like, safe and affordable care.

There had been challenges in implementing changes to the service. For example, moving to an electronic care planning system had not yet been embedded. Action plans lacked robust detail to ensure improvements. However, staff told us that the registered manager was working hard to promote positive changes. People, their relatives, and staff told us that the registered manager was approachable, kind, and empathetic.

The registered manager had identified some areas for development and developed an action plan. Regular management meetings were held between the registered manager and the provider.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. However, not all leaders showed the skills, knowledge, and experience to lead effectively.

Some tasks had been delegated to staff without assuring they had the skills, knowledge and confidence to undertake them, for example mental capacity assessments and best interest decision making.

The service had a registered manager in place. Staff and relatives told us that they were supportive, approachable and always available to answer questions. The registered manager received regular supervisions and on-going support from the provider.

Systems were in place to report incidents and events at the service. The registered manager was aware of their responsibilities to notify CQC and external organisations as required in a timely manner.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager encouraged openness and listened to people’s views.

People and their relatives told us that they felt comfortable to raise concerns if they needed to. One relative told us, “There are relatives zoom meetings every 3 months. I feel able to express my views.”

Staff told us that they were aware of the policies about whistleblowing and complaints and felt confident in speaking up. The registered manager felt well supported by the provider and had regular supervisions to discuss their wellbeing.

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 registered manager valued the diversity of the team, they worked closely with staff to understand cultures, religious and spiritual needs. An inclusive and fair working environment was promoted with staff being encouraged to understand and learn from each other.

The registered manager had completed additional training in specialist areas including managing stress in the workplace, mental health and employment law and menopause, to support workforce wellbeing and equality.

Staff had completed equality act training as part of their inductions. Policies relating to equality, diversity, religion and beliefs were in place and had been recently reviewed to ensure that they were fit for purpose and inline with relevant legislation.

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.

Governance systems, processes, and over sight did not always effectively identify poor care or drive quality improvement. Audits had not identified that care plans were not person centred and contained discrepancies. Records were not always kept to evidence best practice. For example, mental capacity assessments did not include details to evidence all elements. Medicine audits had not identified the medicine policy was not being followed.

The registered manager and the provider had completed an improvement plan which had identified that both the exterior and interior of the building needed updating. The provider was aware that investment was required and building work was underway on the day of inspection.

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.

The registered manager had built relationships with organisations that helped to improve people’s experience of living at the service. For example, a program had been devised in partnership with a local children’s nursery to bring people together through activity.

People were supported to access a range of different services and agencies this included health appointments. Staff and the registered manager liaised with other professionals to promote continuity of care.

People and their relatives were involved in regular meetings where they were prompted to share their views and provide feedback. Staff were given the opportunity to contribute towards improvements through team meetings, individual supervision and appraisals.

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.

People were not always involved in reviews of concerns, accidents and incidents. There had been analysis of accidents and incidents to identify areas of learning and improvement however, actions to ensure that these had been followed up had not always been recorded.

The provider did not always ensure that processes were implemented in response to adverse events. For example, following a recent pest outbreak, there was no guidance developed to outline how this should be managed locally or to ensure that appropriate control measures were in place to minimise the risk.

The digital care plan system was not well embedded. This impacted the quality-of-care planning and daily recordings. The registered manager advised they were planning to request support with the system to ensure its use could be maximised.

Staff told us that the registered manager supported additional training to enable them to further develop their skills and knowledge.