Poppy Court Extra Care and Outreach

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

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 changed to 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 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 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 positive culture in the service which focused on kindness, supporting people and changing lives. Staff spoke highly of the registered manager and how their leadership, compassion and their commitment supported people and staff. They felt listened to and reported management always took their suggestions on board. One staff member told us, “I am very supported, well respected. Not very often there are issues, but they are always dealt with.”

Monthly staff meetings included a de-brief on updates and sessions on lessons learnt. Copies of minutes of meetings were distributed to staff for reading and signing. Managers ensured staff received a full induction, training and support to help them provide good quality care. Concerns about staff conduct or practice were addressed through supervision and recorded appropriately.

Housing incident reporting processes supported communication between the provider and landlord. Systems were in place to support safe practice, including a ‘What if’ folder providing clear guidance for staff in the event of emergencies, medication errors, accidents, or other incidents.

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 feedback we received during the assessment about the registered manager and team leaders from staff, people and their relatives was positive. Relatives reported management were visible and approachable. Staff told us management treated them well; they were empathetic and provided good communication. One staff member said, “Definitely have the skills, [registered manager] is very visible and will be at the service if needed. I can phone, email at any point. No problems at all, even on annual leave I can get hold of them.”

Leaders were knowledgeable about people’s needs and led a culture of independence and well-being. They demonstrated integrity and had a clear vision for the service which focused on ongoing quality improvement, honesty and transparency. Staff were confident in the leadership, comments included, “Good team here.” “[Registered manager how they handle management role, they know what they are doing.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistleblowing policy in place which staff were knowledgeable about, they expressed confidence in and able to raise concerns and that these would be listened to and acted upon. Staff shared how lessons learnt meant they could develop and move on. There were several ways staff could raise concerns formally and informally with different members of the senior management team. For example, one staff member explained, they could go to the Team leader, registered manager, regional director or human resources (HR).

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 demonstrated flexibility and care for the staff team and encouraged to treat people well regardless of their background. Staff gave examples of collaborative working to support with childcare or personal health appointments. One staff member told us, “There is an open door policy, I feel very lucky to get the support. Would struggle with everything going on in my life if I didn’t have the support from registered manager.” The registered manager gave examples of flexible working arrangements offered to staff following a medical procedure. The provider undertook quarterly and annual audits as well as anonymised staff surveys to identify improvements.

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 provider had robust governance systems in place to monitor the quality of care delivered to people. This included regular audits of accidents and incidents, medicine administration and care documentation to ensure people’s care needs were met. Routine checks, spot checks and staff competencies identified areas of improvement. In addition, the provider commissioned an external provider to complete audits with actions identified and included on the service improvement plan.

Staffing was planned and a structured rota supported individual needs. Key-worker systems were in place and service reviews captured the views of people who used the service, their relatives and staff. This information helped the provider to evaluate and audit service delivery and was used to improve the quality of care provided.

The registered manager understood their responsibilities and reported concerns to relevant stakeholders including Care Quality Commission.

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.

Management and staff worked with relatives, health and social care professionals, local authorities and voluntary organisations to ensure people accessed services to drive improvements. Examples of good practice included working with physiotherapist and occupational therapist to reduce falls for person by connecting sensor mats to staff mobile phones. This alerted staff to go in and check on the person which helped to reduce falls and remain at home. Another example, provider invested in a portable lifting device designed to lift people who had fallen to the floor back to their feet. This prevented waiting for paramedics and person could be assessed sooner. People were supported to maintain links with their relatives, friends and the local community. The provider organised for outside agencies to speak with people and provide information such as Fire service and mental health services.

Records we viewed and conversations with management and staff demonstrated openness and transparency. The registered manager had a proactive approach and shared learning experiences with colleagues from other Extra Care services. Systems were in place to ensure referrals made to outside agencies were followed up and any outcomes monitored.

The provider 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 contributed to safe, effective practice and research.

The provider had independent audits and completed routine reports as another means to assessing the quality and delivery of care. They audited the service and produced reports for the provider and registered manager. This had helped to improve the overall performance and contributed to driving improvement, learning and innovation.

The provider actively worked to secure donations by fundraising opportunities to enhance service delivery. For example, funds used to purchase specialist equipment and extra hours of support for people who did not have family to access day trips and outings.

There was a learning culture driven by the willingness to improve service delivery. The management team shared good practice across the organisation and shared action plans and lessons learnt on their internal system for sister homes to prevent future occurrences.