Enbridge House 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 there are effective governance and management systems. Information about risks, performance and outcomes is used effectively to improve care. At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. The providers have developed their processes to monitor the service, and the service is now more outward looking. They are working closely with external partners to provide people’s care safely and make improvements for them. The providers have made improvements since the last assessment and taken sufficient action in relation to governance, so are no longer be in breach of regulations. However, although improvements have been made, further time is required for the providers to fully embed some of their processes, especially in relation to the oversight of staff training as a whole and supervisions, and systems to ensure all required tasks are completed in a timely manner.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they had learnt about the provider’s vision and values for the service. The providers said they had been working with the staff team on improving the culture of the service. They said following the last assessment they had been open with staff about the required improvements. Staff had all been asked to read the last CQC report which was also discussed at a staff meeting. The deputy manager told us they also sought people’s views at the resident’s meetings. This year people had once again wanted to do a fundraising project. We saw people and staff completing their ‘chair burpees’ together in order to raise money for the national ‘Children in Need’ appeal.

There was a positive culture, based on collaboration and a motivation to improve. The deputy manager had introduced pictorial ‘templates’ for staff to complete daily for different types of incidents such as falls and skin tears. This both enabled them to have an instant overview of the number of each type of incident which occurred, but also motivated staff. As staff could see as a team how well they were managing to keep incidents rates down across the month. There was a greater level of engagement with external partners which had both increased external oversight and enabled staff to be better supported when identifying what improvements to make for people and how. The providers completed a weekly walkaround to monitor the service, which included seeking feedback on the service from people, residents, and professionals. The registered manager and the deputy manager had both completed training on equality, diversity and inclusion and workforce wellbeing.

The providers and the deputy manager were highly visible in the service, which relatives confirmed. The deputy manager had grown in confidence in their role and responsibilities since the last assessment. Staff were positive overall about the management of the service. Staff said management helped them as required.

The registered manager who is also one of the 2 providers had reduced their working days within the service. However, the providers were planning for the future. Staff had been identified for development and given additional areas of responsibility. In addition to the providers, there was a full-time deputy manager and senior care staff. Other staff were also being supported to undertake professional qualifications as part of their professional development. There was a service improvement plan which set out the providers plans for the service and for staff development over the year. The providers had recognised the benefit of seeking additional expertise and guidance to support them in areas such as health and safety, which they had sought.

The providers told us staff were told to speak with them about any issues. The management team were readily accessible to staff as they worked with them on the floor providing people’s care. Staff knew they could also go into the office and speak with the management as needed. Staff could also raise issues during their supervisions, staff shift handovers or staff meetings.

Processes were in place to enable staff to speak up. Staff had access to the providers whistleblowing policy which set out the actions staff should take to raise any concerns.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The providers had made improvements since the last assessment. They had taken sufficient action in relation to governance and are no longer in breach of regulations. The deputy manager showed us there was now a robust system to monitor and evaluate incidents and to identify any emerging trends. This information was then used to identify and plan staff’s future training needs. However, aspects of their systems needed to be further embedded to ensure they were fully effective. The providers and the deputy manager told us they were each responsible for having oversight of a different aspect of the service which they then monitored via their governance planner. Although the management team told us they spoke daily and also had a weekly meeting to discuss any concerns. They had not always identified that required actions had always been fully completed. Their processes to verify each other's work was complete and to ensure all required actions were finished, required further time to become fully embedded.

Processes were in place to monitor people's weights and relevant actions had been taken if required. The deputy manager was also in the process of introducing a new audit to enable them to monitor any wounds people experienced. Staff audited aspects of the service such as health and safety, medicines, and infection control. The providers told us staff training was recorded on 2 systems, which we found had impacted their oversight of training compliance across the staff team as a whole. Although staff had completed a lot of training overall. The providers had not identified that not all staff had completed their COSHH training or that 4 of the medicines trained staff did not have an up-to-date medicines competency and 2 staff needed to refresh their medicines training. There was no evidence this had placed people at risk and the providers acted immediately to address this. The providers told us afterwards, having reflected on the issue; they were now looking at changing their online training provider. The providers also needed to ensure systems used to have oversight of when staff supervisions were due and completed were fully robust. The providers need further time to continue to complete and embed these changes in order to demonstrate they are fully effective.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.