Maldon House

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 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 inspection 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. The management team were continuously implementing changes within the home to have a positive impact on people. The management team worked hard to ensure staff had job satisfaction and were equipped with the skills they required to carry out their duties and deliver high bespoke quality of care. Electronic care systems and good management oversight meant care plans, medical health plans and PBS plans were reflective of people’s care, support and health needs and were up to date.

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 had been changes in the management and staffing structure in the last year and positive feedback was received about these changes, comments from staff included, "[The manager] has done so well and turned it around, a happy place and I enjoy coming to work, I know I will have a good day and love the residents." Ongoing improvements were taking place within the home and people were involved in decisions about their home.

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. There was no registered manager at the service. However, the manager of the home was currently in the process of registering with CQC. The manager attended regular manager conferences with the provider to further improvement and develop personal skills. Relatives told us about the management team, "Yes very approachable. They don’t have anything to hide. Whenever I want to talk to the manager, [manager] is always there and always responds to me and always tries very hard. [Manager] does always acknowledge my request." Other relative comments included, “Since [manager] has become manager a lot of things have been improved.” “The current management seems to be quite proactive and is really good."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was information around the home about how to report concerns and this was also available in different formats and staff satisfaction surveys were carried out. Staff told us how they felt the management team were all approachable and they could speak with them at any time and that they had an open-door policy. People were involved in ‘people we support meetings’ and people were encouraged to be as involved as possible.

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 manager told us how they had worked hard on improving the culture and staff morale had improved. Staff told us’ "There is always [manager], we can talk to her whenever, always doors open, we also have RADAR well-being support, can talk to my team, we are all very close."

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. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. The home and provider ensured that people had opportunities and equal rights, and this was continually being adapted and improved. The management team had effective quality assurance oversight and carried out regular audits and checks to monitor and improve all aspects of care they delivered. Quality assurance audits happened quarterly with external auditors. The home had a new electronic system in place called RADAR and all policies and electronic records were stored there and this highlighted when action was required. There was also an action plan for the current year that the management team were working towards.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The manager told us how they practiced lessons learnt in team meetings, identifying areas of training required. There were effective systems in place for reporting incidents and accidents and staff told us about the ease of reporting by scanning a QR code to access forms. After certain incidents staff members discussed with people what had happened including their emotions and behaviours if appropriate and helped to identify what could be done differently.

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 manager told us how she attends manager meetings and has ongoing support and training to improve her knowledge, skills and has a good support network from the area management team. Lessons learnt and complaints were followed in team meetings and with staff and families. In line with best practice guidance right support, right care, right culture staff had tailored training to maximise their knowledge and ensured they delivered a high quality of care. Staff attended regular staff meetings, and all felt they were beneficial.