Archived: Stanholm Residential Care Home for the Elderly

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• 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

The key question of Well Led was rated as good at our last inspection, however, at this assessment we identified a breach of the legal regulations. The provider and registered manager did not have oversight of the service. They had not identified shortfalls in the quality of the service, had not identified when people were at risk and had not ensured staff had the skills to meet people’s needs.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We were not assured that processes were in place mitigate the risk of closed culture. The registered manager had not risk assessed relatives working together in the service. The registered manager told us relatives did not work together. However, they had not considered the fact one of relative was in a senior position, which could make it difficult for staff to raise concerns about other members of the family. There was no effective system of supervision for staff to raise concerns or identify shortfalls in practice. The registered manager did not have oversight of when staff last received supervision. Senior leaders had not taken responsibility for finding out or sharing information about people and any changes or updates with their health. There was a lack of direction from the registered manager, staff had not received clear leadership, oversight or responsibility.

Staff told us they had received some supervision, "Yes, I think I have had about 3 or 4 since I started about 2 years ago. I think they are useful there might be something they pick up on. I personally wouldn't want anymore but I think it depends on the person, specially if someone has never done care before"

There were no effective governance systems and processes were in place to identify issues and ensure there was continuous learning and improvement. The management team had failed to ensure quality assurance audits were effective at identifying shortfalls in safe and effective practice. There were no effective systems in place to identify and assess risks to the health, safety and welfare of service users. People's support plans were not person centred when people had specific health risks such as epilepsy. There were failures to ensure there was sufficient and robust oversight at the service to for service users’ safety and wellbeing.

The culture within the service was not positive and did not encourage staff and people to speak up. Leaders did not take responsibility for finding out and sharing information with and about people and any changes or updates with their health. Senior staff did not take steps to involve people when health professionals visited to discuss their health. There were no processes in place to gather feedback from people to improve the service.

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 registered manager was aware the systems in place were not effective in monitoring the quality and effectiveness of people's care. The registered manager told us when people were supported by the district nurse they did not check to make sure people received visits and what was happening, they told us, "Usually the district nurse does the checks, if it flashes then we call the district nurse.’ The registered manager knew there was not an effective system in place to learn lessons when things go wrong. The registered manager told us, ‘We have a chat but we don’t write things down. We really need to do a lessons learnt’

The provider and registered manager did not carry out robust auditing or checks of the service and had not identified any of the concerns we found during our assessment. The provider had not effectively identified and managed risk, placing people at significant risk of avoidable harm. We identified widespread and significant shortfalls in the management of risk and delivery of care, for example supporting people's health needs, especially in regards their skin integrity. falls management, weight loss and medicines.

Staff did not work in partnership with other healthcare professionals. We asked the registered manager about people's wounds. The registered manager did not know and asked the care co-ordinator and they said "not my shift not my problem". Another told us they had been on leave and so they were not aware the registered manager did not know about wounds. The care coordinator was asked about how action is taken from ward rounds and district nurse visits. They told us there was not anything normally said on the ward round and not many actions. "We log it onto people care notes and then the registered manager will look at the care notes and follow up any actions."

Healthcare professionals we spoke with were not confident staff were supporting people in the way they had requested. They gave examples of tests not being collected and completed by staff when people had become unwell. There were concerns raised about how decisions had been made by the service which affected people's care and wellbeing.

The registered manager failed to have systems in place where information could be shared by other health professionals and appropriate action taken and followed up. There was no evidence this system had been effective, as information had not been collated to ensure the action has been taken.

We asked staff about their learning and how they were supported to improve care and support for people. Staff told us they did not have regular staff meetings, one staff member told us, "I can not remember the last time we had one. It might be one when I was away. Usually get an email. The senior leaders verbally tell most of the time if there are any changes with peoples needs."

There was no evidence of continuous learning. We asked the registered manager for the analysis of incidents at the service. No analysis of incidents had been completed by the provider or management of the service. Other risks associated with people were not known, therefore action taken to reduce the likelihood of harm had not been considered.