- Care home
Service to the Aged
Report from 15 April 2024 assessment
Contents
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 - we rated this key question as good. Leaders supported staff and collaborated with partners to deliver care that is safe, integrated and person-centred. The ethos, values, attitudes and behaviours of leaders and care staff ensured people using services led confident, inclusive and empowered lives. This service scored 64 (out of 100) for this area.
This service scored 64 (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 was committed to a shared vision, strategy and culture. The management team and staff understood the need for transparency, while promoting equality and human rights, diversity and inclusion. They respected the challenges and the needs of people within their community in order to meet these qualities. It was evident from our inspection there was a positive culture in the home which was led by the manager. The manager was passionate about the staff, the people in the home and their vision for the service. Staff spoke very positively about the manager. A member of staff said, “The manager and deputy are really good and very approachable." Comments from people and relatives included, "[Manager] is a very good manager. I like her. In fact [manager] is special and like everyone, is very respectful. Another comment was, "Everything is fine here and I feel the place has got better more recently; things run smoothly and we have a manager who gets around." A relative told us how their family member's mental health had improved over the past 18 months. They said, "[Family member] is very happy here. They are very clean and well looked after. Everything is spotless, the food is good. [Family member] is smiling now. They never used to smile as much."
Capable, compassionate and inclusive leaders
Feedback we obtained was positive about the direction of the home and inclusivity of its leaders. The manager was aware of the need to be open and honest and act with integrity. Their values and ethos matched those of the provider to ensure care, treatment and support was delivered effectively and embodied the culture and values of their workforce and organisation. Staff told us the manager had the skills, knowledge, experience and credibility to lead effectively. The manager led by example and promoted a positive and inclusive culture where staff felt supported and valued. A member of staff said, “[Name of manager] is very supportive and passionate. We work really well together. It's a nice place to work." The management team had planned staff workshops to discuss how they could all contribute to the wellbeing of staff and maintaining the values of the home.
The manager was supported by a deputy, a consultant and by other senior staff to monitor the day to day running of the home. The manager encouraged staff and supported them in their roles to deliver care that met people's needs. Staff were provided with ongoing supervision. They were able to discuss their performance and any issues with their line managers. They were provided the tools and skills needed to carry out their work effectively. Feedback from people and relatives was positive about the staff, who they said were kind and compassionate towards them. Staff told us they respected people's privacy and dignity. They bought into the culture of the service and said that managers were capable, caring and compassionate in their work. This ensured people were treated well.
Freedom to speak up
We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.
Workforce equality, diversity and inclusion
There was a policy to ensure all staff had access to equal opportunities and reasonable adjustments to ensure their needs could be accommodated in the work place. Staff told us they were treated well and were supported in their role. The management team ensured equal opportunities for staff were maintained. The manager said, "Yes we are a Jewish nursing home but we employ staff from around the world. We have staff of all religions, [such as Muslim and Christian staff]. Staff have multiple backgrounds and cover lots of different languages. We do not show or promote any form of discrimination."
Recruitment, disciplinary and capability processes were fair and were reviewed to ensure there was no disadvantage based on staff's specific protected equality characteristics. The provider had processes to ensure an inclusive workplace where staff were treated and supported as individuals. Staff told us they were able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example if they had family commitments or religious needs. Staff told us they were able to take breaks and their health and wellbeing was taken seriously by managers.
Governance, management and sustainability
The manager and staff team were aware of their roles and responsibilities. The manager was working with an external consultant to help carry out audits and maintain the management of the home. We saw records of audits to monitor and improve the home. These included audits of people’s care plans, medicines, the environment and infection prevention and control procedures.
The manager told us about the audits and checks in place to monitor and improve the quality and safety of the service provided. Staff explained the systems in place to audit people’s care plans, medicines, the environment and infection prevention and control procedures. There were effective systems in place to monitor and improve the quality and safety of the service provided. Where areas for improvement were identified, there was a plan in place to ensure improvements were made within agreed timescales. However, the home is required to have a manager that is registered with the CQC as part of their conditions of registration. The manager confirmed to us they had made their application and this was in progress at the time of our inspection.
Partnerships and communities
The provider shared information and learning with partners and collaborated with them for improvement. People were supported to access the healthcare services they needed. Staff told us they had built good working relationships with health and social care professionals and worked in partnerships with them to achieve good outcomes for people. Health and social care professionals told us staff worked effectively with the service. The manager understood the importance of collaborating and working in partnership. However, prior to our inspection we received concerns about a lack of responsiveness from the management team to engage with partners but we found this issue to be resolved. The manager told us they always arranged for cover when they went on leave and would ensure any call requests from professionals in future would be followed up.
Learning, improvement and innovation
Staff and managers told us there was a culture of continuous learning, innovation and improvement across the service. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Forums and workshops were taking place for staff and people so that their feedback could be obtained. A staff member said, "Yes we go over things in staff meetings. We are always learning. Things are going well at the moment."
There were meetings for staff where information was shared and views were encouraged, listened and responded to. Staff meetings included topics such as medicines, care plans and handovers. People could also express their views in annual satisfaction surveys and meetings. Relatives had opportunities to meet managers in groups to discuss updates about the management and activities. A person told us, "Overall, I feel grateful that the home has taken me with my complex needs, so really, I should say this place is superb!" Lessons were learned when things went wrong in the service. For example, following an incident involving a person's PEG tube, all nursing staff had updated training to remind them that their responsibility and obligation is not only to document but to escalate any concerns immediately to the relevant health professionals.