United Response - 29 Mayfair Avenue

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. At this inspection, the rating has changed to good. This meant the service was now consistently managed and well-led.

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 service 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 registered manager described the values of the provider and explained how these were applied to ensure they employed suitable staff. They told us they routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles. They supported a reflective practice approach, establishing a learning culture to support staff to deliver good quality care. Staff told us they were supported by the registered manager to deliver consistently safe, person-centred care to people in line with the provider’s vision and values for the service. A member of staff told us, “This is a good place to work. We have an excellent team spirit and we work together well like one big happy family.”

The service 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 services long standing registered manager was responsible for the day-to-day running of 2 similar sized care homes located in the area that sat under this provider. The registered manager was suitably skilled, knowledgeable and experienced. The feedback we received from people living in the care home and relatives about their leadership approach was positive. A relative told us, “[name of registered manager] is an exceptional manager. We have a great relationship with him and he always has the best interests of everyone who lives at the care home.” Another added, “The service is well run and we feel able to discuss any matters with the manager.”

Staff were equally complimentary about the leadership approach of the registered manage who they consistently described as effective, professional, and friendly. One member of staff told us, “I feel 100 percent supported by the registered manager and all the staff we work with here and at the other sister home. This is a great care home to work in.” Another added, “The manager [registered] is such a lovely man. A really nice chap who is always so friendly and approachable. The managers door is always open.”

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

The care home had an open and transparent culture where people, relatives, external care professionals, and staff were all encouraged to raise concerns without fear. A relative told us, “Our comments are always noted and a good example was where we considered the front door entrance to be a little unsafe for [name of family member], so the manager acted quickly for a new safer step and rails to be fitted.”

The provider used a range of methods to gather people’s views about what the service did well or might do better, including through regular individual meetings with their allocated keyworker, care plan reviews, and satisfaction surveys. Relatives told us they felt comfortable raising concerns with the managers and felt listened to. Staff were encouraged to feedback concerns on behalf of people or their representatives and to record them in their care notes.

The provider valued and listened to the views of staff. Staff were encouraged to contribute their ideas about what the service did well and what they could do better during regular individual and group meetings with the registered manager and fellow co-workers. The provider had a ‘Speak up’ policy that was available to all staff. Staff felt able to brings things to the attention of the managers.

The providers complaints policy was displayed in the care home, which detailed how people could raise concerns if they were dissatisfied with the service and the process for dealing with them. Formal complaints raised were logged, investigated and appropriate actions identified and taken to improve the service.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they were part of a diverse team, treated equally and fairly, and they felt able to speak up. Staff told us their managers were supportive and reported feeling cared for, respected, valued and listened to by them.

Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The provider had improved the effectiveness of how they operated their governance systems as we had recommended at their last inspection. They had introduced an electronic IT recording and monitoring system that immediately notified them if audits and checks had not been routinely conducted in accordance with the providers established quality assurance policies and procedures. For example, regular monitoring checks were now carried out in respect of medicines and finances they managed on behalf of the people living at the care home. In addition, the electronic monitoring system automatically notified managers when staff had not refreshed their mandatory training or risk management plans had not been reviewed at regular intervals, which had been identified as an issue at their last inspection. Overall, the providers governance systems were now more effectively operated to regularly check and audit the quality and safety of the personal care and support people living at the care home received.

The quality of information recorded and maintained in people’s electronic care records, and records relating to the management of the service had improved. This meant they were now sufficiently detailed, person-centred, and accurate.

The outcomes of these improved monitoring checks and audits were routinely used to identify issues, make any changes required and support staff to improve their working practices. This all feed into an action plan to continuously improve the quality and safety of the service people living at the care home received.

The registered manager and staff demonstrated a good understanding of their governance roles and responsibilities in relation to assessing, monitoring and managing the quality and safety of the service they provided. The registered manager understood their responsibilities in relation to regulatory requirements around notifiable incidents. They also understood their responsibility to apply duty of candour and where appropriate apologised when things went wrong.

The service's previous CQC inspection report was clearly displayed in the care home and was easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The provider shared information and learning with partners and collaborated for improvement. Managers and staff told us they worked closely with various external health and social care professionals and bodies who they regularly consulted and welcomed their views and advice. Managers and staff worked closely with the local GP surgery and the district nursing team to jointly meet people’s health care needs. An external care professionals told us, “The service manager and the staff team follow our health care professional advice and ensure additional support is given if anyone’s support plan requires further amendments based on our clients’ changing needs.”

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

Managers understood the importance of having an open culture of learning and continuous improvement to ensure people consistently received safe, person centred care and support. Managers told us all the audits and checks the provider conducted were routinely analysed to identify performance shortfalls and learn lessons, so the service could continuously improve. When the provider identified areas for improvement, they developed action plans that clearly outlined the necessary steps, methods, and timelines to enhance their service delivery. Staff confirmed information about any lessons learnt and action plans developed as a result were always shared with them during individual supervision and performance appraisals meetings with the registered manager.