The Shrubbery Nursing 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 we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question good. The overall rating for this key question remains good.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Staff told us they were happy with the support they received from managers. They referred to an "open door" policy where they could share concerns, which would be listened to and acted upon. One staff member said: "(Registered manager) is an amazing support, they encourage us to develop and helped me find courses to renew my [nursing] pin.” Another staff member said, "Staff are lovely, like family, it’s really nice to work with them". Staff told us they had the necessary training to complete their roles effectively and had the option to develop their knowledge further if they chose to. The registered manager told us they felt supported by the senior management team. They said there was good communication and shared knowledge between the providers’ services and information was shared with each manager. They said they had regular team meetings and completed weekly reports. This detailed any changes at the service, staffing and recruitment, changing to people's care needs, and any concerns which needed action. They told us they had support from the senior leadership team and felt confident to ask for support if needed.

Surveys had been completed from people and relatives which showed that staff and management were caring and listened to peoples’ concerns and views. The manager has ensured safeguarding concerns have been dealt with appropriately. Staff spoke positively of the Registered Manager and told us the service was well managed. They told us the registered manager had the skills and knowledge and this has had a positive impact at the service. The staff felt supported, and able to raise any issues or concerns openly.

Staff told us they were able to speak up and voice their opinions. They were confident they had been listened to. One staff member said, “We are listened to, nurses are fantastic. Management is supportive.”

Processes were in place to enable people and staff to have the confidence to speak up to highlight any concerns such as the whistleblowing and complaints policy and procedures. Staff said when they speak up, they were listened to and heard. We observed a culture where staff and management acted with openness, honesty, and transparency. There were clear systems and processes in place allowing staff to raise concerns without fear. When concerns were raised the management team listened, investigated if needed and lessons learnt were shared with staff team.

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 told us they were based between 2 services. In their absence on site, the clinical lead manages the service. The management team outlined how they met their governance responsibilities. They completed internal audits and checks and compile a weekly report to share with the senior leadership team. Staff told us they understood their roles and responsibilities within the team and had made suggestions on improvements. We discussed some of the issues of our assessment, and saw the registered manager took appropriate action to address these. The management team were aware of when to notify incidents to relevant external agencies.

The Registered Manager implemented a range of effective audits and monitoring tools to identify concerns, risks, and areas where improvements where needed. The audits provided the management team with an oversight of the service. For example, there were audits in place to check care planning records, medicines, health and safety, infection prevention control and incident and accidents. Statutory notifications had been reported to CQC in a timely way. The Registered Manager completed daily walk arounds to check people were supported appropriately and check the cleanliness and safety of the building.

The provider worked with external professionals. This was evidenced in people's care plans. We observed a professional visit. Staff had good relationships and shared information about people appropriately. We observed family members visiting and being involved with daily activities.

People were supported to have joined up care and support from other partners to ensure they had better outcomes and could access services that provide specialist care. The staff team and health professionals shared key information and worked together to support people to be more independent with their mobility. Partners confirmed that staff and management always took on board any advice supplied and there was a good relationship between them.

Processes were in place to work openly with a range of professionals to ensure they made the necessary improvements and to ensure people received the care and support they needed to meet their health and social needs.

The registered manager shared their aspirations to improve the outside area of the service to ensure it was accessible for people to enjoy. The service had recently been left a donation to contribute towards a sensory garden. The service was working towards the Gold Standards Framework (GSF). The management team were focused on ensuring they provided compassionate end of life care to people. Staff told us they were supported to develop their roles if they chose to, and had recently received some 1-1 sessions to improve their knowledge on skin integrity.

Processes were in place to ensure staff received relevant induction and training to meet peoples’ needs. Staff were able to identify any additional training needs during supervision sessions. Management acted on these requests.