Mrs A and Mr R Brooks - 5 Everton Road

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

Improvements had been made since the previous inspection in May 2023, the provider was no longer in breach of regulations. There were improvements to the systems in place to monitor the standard of care provided at the service. There was a visible and caring management team who, with staff, fostered a culture that delivered good quality care and outcomes for people in partnership with external professionals. People, family members, staff and an external professional told us they felt the service was well-led. Staff were aware of their roles and responsibilities. Staff felt confident to speak up and that they would be listened to. There were systems in place to share learning.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive and person-centred culture in the service. Staff spoke positively about the people they supported, their work and the management team. Staff were happy in their roles. Staff were clear about the vision and aims of the service. They told us their aim was to provide people with person centred care and support them to achieve their goals and aspirations. One staff member told us, “We are supporting them [people] to have the most independent life they can and live their best life, I think they do.” Another staff member told us, “We want to ensure they are happy and achieve what they would like to, be given the opportunity to live with who they want and live how they want; we do achieve this.” The management team ensured there was an open, inclusive and positive culture in the service. People and staff felt able to approach them and we observed this during our assessment site visit.

The provider had a mission statement in place to support the vision of the service and communicate its purpose to people and staff. Two weekly staff meetings were held to discuss any concerns. The registered manager and nominated individual had regular contact with the homes and good oversight.

Staff spoke highly of the registered manager, nominated individual and the management team. Staff told us they felt able to speak up, not only to raise concerns, but also to make suggestions for improvements, and that they were listened to. Staff felt well supported in their roles. One staff member told us, “I can pick up the phone anytime and talk to [name of nominated individual] or [name of registered manager], it’s dealt with immediately, I feel the most supported I have felt in a job.” The nominated individual told us they valued their staff members and staff felt valued and listened to. One staff member told us, “[Name of registered manager] is very accessible, there is good communication, they are very caring and goes above and beyond for the residents and staff team.”

The nominated individual and registered manager visited the homes regularly and sought feedback from people and staff. Residents’ meetings were held when people wanted to participate in these. Quality assurance surveys were sent out annually to people’s relatives, in 2023 the service received 100% positive feedback from relatives.

Staff felt confident to speak up and that they would be listened to. Staff told us there was an open culture where they were able to raise any concerns. They were aware of the whistleblowing procedure and knew how to report any concerns externally if required. One staff member told us, “I would raise any concerns with [name of registered manager] or [name of nominated individual] and if I thought they weren’t doing anything I would go to the local authority. Although I most definitely know they would take the right action. We have training on whistleblowing, I have never seen anything I needed to report, I feel confident to if I had to, I treat them [people] how I would like my family to be treated.”

There was a whistleblowing policy in place and staff knew how to access this.

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.

At the last inspection we identified a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was not operating effective governance systems to fully assess, monitor and improve the service. At this assessment improvements had been made to the governance systems and the provider was no longer in breach of regulations. There were improvements to the systems in place to monitor the standard of care provided at the service. All of the care plans had been audited, and there were ongoing reviews, improvement to the management of medicines had been undertaken, the recruitment systems in place had improved. We identified some areas of improvement that had not been addressed by the providers systems, such as training being delivered to staff in line with best practice guidance and some improvements to medicines processes. The providers representative showed us their quality assurance audit. Further work was required to fully embed this into the quality assurance systems. The service was a small family run business, the nominated individual, registered manager, and provider representative visited the homes regularly and had good oversight of the service. People received good quality support and achieved good outcomes. The nominated individual was aware of their responsibility to submit statutory notifications as required to the CQC.

Staff were aware of their roles and responsibilities. Staff told us the management team had good oversight of the service, they were visible and visited the homes regularly. One staff member told us, “Yes, I think they [managers] do have good oversight and we let them know anything that is going on, you know they have listened.” The nominated individual told us they were present in the homes regularly and alongside the registered manager they maintained good oversight of them. This enabled them to regularly meet with people to discuss any relevant information or issues. We observed people interacting with the nominated individual during our assessment and it was clear there were good relationships between them and the people they supported. They also told us they held 2 weekly meetings with staff, which enabled any issues arising to be discussed and resolved. The providers representative showed us their new governance monitoring system which they were embedding into the service.

The service worked in partnership with a range of stakeholders and professionals. These included the local authority and a range of health and social care professionals.

The nominated individual gave examples of good partnership and community working. This included working with the learning disability liaison nurse at the local hospital and working with various health and social care professionals. They also had good links with the local community such as local charity shops, clubs and community facilities. The nominated individual also told us that they worked with the local hospital to provide placements for nurse associates, this involved them spending time in the home with people as part of their nurses training.

We received positive feedback from a professional who had worked with the service. They told us staff supported people well, there was a consistent and stable staff team, communication was good, and the homes had a “family atmosphere”.

People were part of their local community. People told us they engaged in a range of local community activities. One person told us, “I work at [name of local supermarket] and help out at a local charity shop. I went on the bus to Street last week.” Another person told us, “I go food shopping and go the farm, I go to the club, disco, into town and to the beach with my friends. We have a meeting and say what we want to do, I am very happy.” Relatives told us their loved ones were part of the local community and were supported to attend a range of activities. One relative told us, “This is one of the ways [name of provider] is impressive, they enable [name of person] to do a variety of things, organised by outside groups, they do a lot.” Another relative told us, “[Name of person] goes swimming, dancing, to the farm, games nights. There is always something in the diary. I just think we were so lucky to have found a magical place for her to be and such a nice team.”

Staff told us they were informed of any areas where improvements were needed. The nominated individual told us following our last inspection they held a meeting with staff to discuss the outcome. The nominated individual demonstrated the learning and improvement carried out following the last inspection, they were committed to providing the best possible outcomes for people. During the assessment they were quick to act on any areas that we identified for improvement.

There were systems in place to support learning and improvement in the home. These included an annual quality survey, resident’s meetings, staff meetings, staff supervision and the complaints procedure.