Sandgate Manor

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 requires improvement. This meant the management and leadership was inconsistent. Leaders had not always supported the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to keeping complete and accurate records and good governance.

This service scored 57 (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. There was a clear improvement in the culture of the service. One relative told us, “I feel the atmosphere is a little lighter.” We observed this was the case and people and staff were comfortable in each other’s company.

Staff told us teamwork had improved, and staff and management supported each other more. One member of staff told us, “The team was welcoming when I started. I have never done a job like this before. I have always felt welcome, it’s easy to feel closed off in a new job, this was the complete opposite.”

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.

Leaders at the service were accessible to people and their relatives. At the time of the inspection the service was being managed by the head of operations who was also the registered manager. People and their relatives knew who the manager was and told us they felt comfortable approaching them. The registered manager clearly knew people well and interacted with people in a positive way frequently throughout the day. Staff were positive about the managers who supported them. One staff said, “I feel supported when I work here particularly by the team leaders.”

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. However, when people and their representatives have spoken up about concerns, they had not always been responded to or given updates about actions being taken.

Staff told is they were able to raise issues and concerns if there were any. One staff said, “The service is better than the before. The manager listens to staff more and asks the residents opinion.” Another staff member said, “I have no reason not to be very free and open with communication, and they are open with me. I can speak to them all, they are a lovely management. They are helpful and don’t bring [staff] down.”

Staff knew how to raise concerns higher up with the provider or externally if they needed to do so.

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 were positive about how they were valued by the provider and the registered manager. Staff were supported to have time to celebrate special holidays with their families where possible. One staff said, “They do value other cultures, they have different decorations and celebrations and make people feel welcome.”

The provider had a system in place to set out responsibilities, roles, systems of accountability and governance. However, these were not always effectively used to manage and deliver quality, sustainable care, and support. Improvement continued to be needed.

Whilst issues had been identified there were areas where there continued to be concerns which had not yet been addressed and needed to be. For example, care plans and records continued to need improvement. Documentation needed to be clearer. There continued to be access issues in relation to the kitchen. The registered manager was fully aware there remained areas where the service needed to continue to improve. Quality assurance systems had identified where improvements were needed at the service. However, not all improvements had yet been delivered and there remained areas where there were still concerns.

Continued improvement was still needed with records as there were areas where the information recorded was not detailed enough and records of people’s care were not as complete as they needed to be. For example, actions in responses to incidents and complaints and best interest decision records. We had identified similar concerns in these areas across the last 3 inspections.

The provider understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement. However, services did not always work seamlessly for people. Some partners did raise that there were times organisation could be improved. For example, when organising training or when information about people’s needs were shared. Overall feedback was positive, and staff worked well with partners to improve outcomes for people. For example, through health referrals for people’s changing needs as people grew older. One partner said, “I think the team have the service users’ best interests at heart and are generally incredibly caring and attentive.”

The provider did not always focus on continuous learning, and improvement across the organisation and local system.

The service had continued to improve the support provided to people, the culture and people’s experience. The registered manager attended local forums and webinars. They were able to tell us what they had learnt and how they’d applied these lessons. For example, when they’d attended learning around modified diets for people with swallowing issues.

However, improvement continued to be needed at the service and changes embedded. Continuity continued to need to be improved upon to ensure people were supported in a consistent manner and had equality in opportunities.