Grove Hill Care Home

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 remained requires improvement. Improvements had been made, however, the service remained in breach of the legal regulation relating to good governance, due to ineffective oversight and policies not always being followed or not containing enough detail to ensure the service followed best practice guidelines.

This service scored 62 (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 at the service. We received positive feedback from people, their relatives, staff working at the service and healthcare partners. The NI explained, “People’s wellbeing is my responsibility, that ensures families are happy, we do what we say we are going to do and we make sure staff share that vision. We also only hire staff who share vision.” Staff also told us they followed the same values. One staff member told us, “It makes a big difference knowing I am part of a team that shares the same values."

The service did not have a registered manager at the time of the inspection but the service was being overseen by the NI, and the NI was actively recruiting a new manager. People and their relatives spoke positively about the current management arrangement and felt it was working well. One relative told described how the NI showed compassion, “[The NI] brought in some shopping for [a person]. She said ‘I haven’t got any money to pay you’, but he said not to worry which made her relax.” The NI had completed a variety of training courses relevant to their role and could confidently oversee the service in the absence of a registered manager. Staff spoke positively about how the service was being managed, and felt this had improved since the last inspection. Staff told us they were now encouraged to use their initiative and that staff felt more empowered to make decisions.

The provider now fostered a positive culture where people felt they could speak up and their voice would be heard. People now told us they felt confident in raising any concerns and felt these would be listened to. Staff supported this. The NI explained staff regularly raised feedback to the NI and staff also confirmed this. One staff member told us, “All staff are given opportunities to raise or discuss things during meetings and if they wish they can discuss any issues personally with a member of management.” Another staff member told us, “There is open door policy, during meetings and supervisions, we were always reminded that our inputs which could be raisingconcerns, sharing ideas or highlighting some things were not working are valued and appreciated. I have raised a concern regarding the care plan of a residentthat needed updating due to my observation. My concern was seriously looked into, the care plan was reviewed and changed.This made me feel listened to and reassured that what I said made a difference.” Staff also told us they would ‘whisteblow’ if needed. The NI also explained how staff could raise anonymous feedback as there was a feedback box in a communal area which the NI checked regularly. There were also contact details recorded of the Care Quality Commission so that staff could raise concerns with CQC if they wanted to. There were now improved systems and processes for people to provide feedback about their care. For example, there were feedback forms following activities which included facial expressions to promote accessibility.

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 NI told us “We give equal opportunities to all staff to develop and grow and better themselves. We offer one-to-one mentoring to all staff where needed to help them grow and develop their skills so to always upskill our staff.” There was a diverse staff team at the service. Staff felt valued in their roles and raised no concerns about equality, diversity and inclusion.

The provider continued not to have good governance. Audits had not always been effective. For example, the service’s medicines audits had not identified discrepancies between MAR charts and PRN protocols, and some missed doses of medicines. Additionally, we found a number of areas where the service’s policies had not always been followed, or policies did always include enough detail to ensure best practice was followed. For example, ensuring the safe disposal of medicines within the service. We also found the complaints policy had not been consistently followed, and the service’s recruitment policy did not follow national legislation. However, there had been improvements since the last inspection in relation to risk management, safeguarding, consent to care, dignity and respect and the overall culture of the service. We received positive feedback from people, their relatives, staff and healthcare partners about the improvements to the governance 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. We received positive feedback from partners who worked with the service. Partners told us staff were quick at escalating any concerns, good at following advice and effective with their communication. Relatives told us people were supported to attend appointments; however, one relative told us they hadn’t been informed about a healthcare appointment, and we saw some previous complaints had been made about this. The NI told us, “Staff are very good at making sure people are getting their healthcare needs met but aren’t always as good at telling families. The priority is always the person, but I have raised this with staff [through a staff team meeting] and asked them to ensure they let families know, they have improved this since."

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. There was a culture of learning, improvement and innovation. The NI told us they kept up to date with articles and research in relation to the sector. We saw learning took place following incidents and complaints and also from feedback from the last inspection. One staff member told us, “One staff member told us, “A lot has improved here since last time you were here; we tried to pick up on feedback that we received.” Another staff member told us, “The home seems to have improved”. The service had met the warning notices served from the last inspection and many improvements had been made.