Archived: Broom Cottage

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 the last inspection (publication date 2 March 2023) this key question was rated Good. At this inspection the service deteriorated to Requires Improvement. 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.

This service scored 64 (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 feedback was overall positive, where staff had raised concerns about management support prior to the new manager commencing, this was known by the management team. Whilst this had been addressed, further time was required for ways of working to become fully embedded and sustained.

The manager was aware of the need to develop and support the staff team, this included developing and upskilling staff’s confidence and skills in some areas. The mix of experienced and new staff was also identified as needing support and development.

The management team was relatively new; But from speaking with them we found they had a shared vision of how the service needed to be developed and had an improvement plan to support this work. The management team supported staff in promoting a positive, transparent and inclusive service that enabled staff to raise any concerns or issues.

The provider had communication systems and processes to share information with staff such as newsletters. Information shared included celebrations, staff well-being, new staff and staff recognition awards and congratulations.

Staff demonstrated a commitment to provide the best care they could for people. The provider's policies were in line with current best practice, and new and improved ways of working was helping to further develop and shape the direction and culture of the service.

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 management team had the required experience, skills and knowledge to manage and lead the service. During the inspection they were found to be open and honest about the areas that needed development and had plans to continually improve the service.

Staff were overall positive about working for the provider. A staff member told us whilst they believed there were areas the service needed to improve on, they were overall positive and described their role by saying, “I do love it here.” Staff gave examples of development opportunities, such as progression to positions with greater responsibility.

The manager told us they had an open-door policy and how they worked alongside the staff team to support their development.

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

Staff were aware of the provider’s policies and procedures that supported them to raise any issues relating to poor practice, concerns and complaints.

Staff told us they felt confident they could use these procedures, and they would be listened to, and managers would take action. Management meeting records confirmed actions taken to concerns raised by staff.

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 provider’s policies and procedures supported equality, diversity and inclusion in the workforce.

Staff were overall positive about working for the provider. Staff confirmed they were respected and treated equally. However, some staff raised concerns about management support and leadership, but recognised improvements were being made.

Staff received regular supervision meeting where they could discuss their work, training and development needs.

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.

The management team had developed an ongoing action plan to drive improvements at the service. They were also reviewing and implementing new and improved systems and processes to support them in the assessment and ongoing monitoring procedures of safety and quality. Further time was required for these to become fully embedded and sustained.

This included improving internet access to ensure staff had consistent access to electronic care records, reviewing how important information about people’s needs were stored to enable easy access by all staff, and supporting the new staff team to develop and upskill in identified areas.

We reviewed a sample of audits and checks and found where shortfalls had been identified, action had been taken to make improvements. This provided reassurance of the effectiveness of monitoring procedures.

Improvements were also being made to staff responsibilities and accountabilities and the management support, oversight and leadership of 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.

Staff worked closely with external health and social care professionals to ensure people’s individual care and support needs were fully known, understood and met by staff. This was evident from people’s care records that confirmed there was a collaborative approach and recommendations made by external professionals were implemented.

Feedback from a healthcare professional was positive, they told us communication with the service was good, and how staff supported people to ensure they received their annual health checks time.

The provider’s systems and processes were being further developed to ensure they were sufficiently robust and effective in relation to continued learning, improvement and innovation.

New management roles had been developed to enhance the oversight and leadership of the service. However, further time was required for new and improved systems and processes to become fully embedded and sustained.

Whilst there was shared learning across the organisation, the manager was in the process of developing links externally, such as forums they could participate in to enhance leaning, improvement and innovation opportunities.