Isabella’s Home Ltd

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.

This is the first assessment for this registered service. This key question has been rated good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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.

Leaders and staff described the values of the service as ‘supporting people to gain independence’. They shared examples where people had made significant improvements within the service where this had not been the case within previous services. The provider organised educational events where guest speakers could talk to staff about care work and the impact and importance their work has on people they support.

Staff spoke positively about the culture of the home. There were processes in place to ensure there was a positive culture in the home. This included ensuring the wellbeing of staff and ensuring staff had received training that gave them the skills and knowledge to promote a positive culture.

Leaders demonstrated experience and knowledge; however, we identified issues that had not been recognised by them.

Although safeguarding processes were in place and incidents were reported and investigated, leaders had not reported all safeguarding notifications to CQC in-line with regulatory compliance. Additionally, monitoring systems for medicines storage were not in place to ensure minimum and maximum temperatures were recorded, to ensure storage of medicines remained within safe temperature ranges.

However, staff we spoke with told us they believed the registered manager to be approachable and fair. Staff told us they were confident raising any concerns they had with leaders and had done so before. There was a clear governance structure, and staff knew their roles and responsibilities.

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

There was a whistleblowing policy which identified a named staff member as the ‘freedom to speak up guardian’. Staff we spoke with were aware of these procedures and told us they felt confident action would be taken if they had concerns.

The provider valued diversity in their workforce.

There were procedures in place to consider the individual needs of staff. This included showing regard for staff’s diverse needs and treating all staff fairly and equitably. Where the provider identified a need, staff were supported in their roles with reasonable adjustments. Staff raised no concerns with how they were treated.

The provider had clear responsibilities, roles, systems of accountability. However, systems of governance were not always effective.

There were audits in place which monitored the safety and quality of care, including management of medicines and the care people received. However, audits in place had not identified discrepancies within electronic medicine administration records (EMAR) and protocols relating to ‘as required’ medicines.

However, where areas for improvement had been identified and discussed with the provider, they told us they had made changes where required. There was a system in place to monitor and review accidents and incidents that had occurred.

The provider had contingency plans in place to be implemented should there an emergency arise. For example, additional systems were in place to ensure there were staff available at times of unexpected absence.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning and collaborated for improvement.

There were systems in place to ensure the provider worked in partnership with other agencies. The registered manager gave us examples where they had made referrals to other professionals for advice or support.

The provider actively sought external feedback, this was obtained by inviting external audit agencies to carry out audits and were open to making changes where improvements had been identified.

The provider focused on learning, and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The systems in place were used to drive improvements throughout the home. When incidents or safeguarding had occurred, the registered manager ensured lessons were learnt from this. Learning from incidents was shared between services and where trends or themes were identified actions were taken to address them at each service.

Staff were encouraged to discuss and document approaches to people following any changes in their emotions, where these had been effective approaches were shared via updates to care plans and shared with other staff to improve the experience of the people they work with.