Sandhall Park

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 governance systems in the service needed to improve. The recording of management checks and oversight processes needed to improve to help evidence a consistently good standard of care.

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’s culture 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 management team championed a culture of openness and honesty which was mirrored by the staff team. However, there was a lack of clarity across the management structure within the service regarding the oversight of care. This meant those managers and senior staff responsible for checking people received quality care did not always have a clear shared vision about how this would be achieved, monitored or recorded. The provider had recently reviewed the governance system and was working towards creating new processes to help ensure a more robust approach. This had not been fully implemented. More time was needed to fully embed new practice and cement the shared direction and vision for the service regarding its governance systems.

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 and knowledge to lead effectively. They did so with integrity, openness and honesty.

The registered manager and deputy manager were passionate about providing good care to people. People and staff told us the management team were capable and inclusive leaders. One family member said, “(The registered manager) is lovely and I am confident that she would tell me if there were any issues. If I had concerns, I definitely feel that I could discuss them with her without a problem.” One staff member said, “The managers are both knowledgeable and approachable.”

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

Managers lead with an ‘open door policy’ which meant people, staff and families could approach management at anytime if they had any concerns. One staff member told us, “It is a good team, there is an open-door policy, and we can go in at any time.”

Opportunity to speak and share views was offered within the staff meetings with managers taking on board people’s comments and acting on them when needed.

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.

There was an inclusive and fair culture with equality and equity for staff. All staff were positive about working at Sandhall Park and felt they were treated with respect.

The registered manager had good oversight of the service, however, the recording of this required improvement. Staff and the registered manager could tell us additional checks were taking place to ensure the care provided was to a good standard, however this was not always recorded. For example, additional spot checks were taking place throughout the day to ensure cleanliness and peoples safety but there were no records of this. Governance systems in the service needed improvement. We found that not all governance audits which were in place at the time of the inspection were effective in providing oversight of all care areas. This had been highlighted by the provider at the time of the inspection and new auditing systems where in development, however these had not yet been implemented. People’s care plans were still underdevelopment and while staff knew people well to keep them safe, not all risks to people had been recorded. For example, people who were at risk of developing skin issues did not have appropriate risk assessments in place. The deputy manager was developing these following our inspection, but more time is needed to ensure all people who presented with additional risks had this recorded within the care planning system. Other areas of people’s care records needed expanding to ensure people’s needs and preferences were recorded in full. The registered manager and deputy manager were working to update records, but more time was needed to embed good practice around record keeping within the service.

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 management team expressed an open positive attitude to receiving support and understood how and where they could access support, to ensure continuous improvement to the service. Strong relationships had been built with community health care providers which helped improve outcomes for people.

The provider encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had made investments into the service to help innovate and improve. For example, a new electronic care record system had been introduced with the aim of improving records and oversight of people’s care needs. However, more work was needed to clearly evidence continuous learning.

The registered manager had oversight of the accidents and incidents within the service. However, it was not always clear if staff had learnt from when things went wrong. Records needed to be more robust to show continuous learning. The registered manager took onboard our comments at the time of the inspection and developed a new debrief process to help address this.