Dormy House

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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

We identified 1 breach of the legal regulations. We found the provider did not always ensure all of the issues we found during this assessment that are described throughout the report, were identified through their own quality monitoring systems. Governance systems and audits had to be reviewed and improved to ensure it was more effective and consistent in identifying or addressing areas for improvement. However, we also received positive feedback professionals, staff and relatives about the manager, the staff team and the work they have been doing which had a positive effect on the service. The manager worked together with the staff team and proactively sought support and advice from external partners to ensure any improvements needed were identified and implemented swiftly. People's and relatives', and staff’s feedback were sought and used to make improvements to the service. Relatives said they could approach the manager and any staff with any concerns. The manager appreciated staff contributions and efforts to ensure people received the care and support.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The manager and the staff team demonstrated a shared responsibility for promoting people's wellbeing, safety, and security. The manager established a 'whole team approach' and culture in the service and worked with the staff to ensure it continued to develop and grow. The provider supported the manager and the service to follow the shared vision, strategy and culture that would ensure provision of good services to the people. The manager was motivated to provide the best possible care for people and staff were aware of this through training and caring for people. They said “I always like my staff to tell me solution rather me telling them what to do. I am here when they need me, and they want me to confirm what they do is correct. If it does not work, let’s try something else, as long as it does not hurt anyone. We have to innovate as the world is evolving, to ensure we do our best for our people”. Any changes were discussed together with staff and/or other relevant parties to make those changes. The manager praised their staff team for positive engagement and added, “You can only make changes if staff are working and engaging…the staff are not resistive, they are so engaging...When you discuss things with them, what we need to do, they will work with you as long as they know you are there with them and guide them”. The manager worked with staff to ensure equality and diversity were actively promoted, and the causes of any workforce inequality were identified, and action was taken to address these. Staff were very positive of the changes being made since the new manger joined the service which supported the learning and a number of improvements. They said, “Manager is very good”, “No one’s hiding any more. Relatives see them (managers) a lot” and “I see a total improvement from before. Staff are more relaxed. Staff open up and ask questions.”

The staff team used shift handovers, regular meetings and daily communication to share and discuss any tasks to complete or what was going on in the service. The manager worked alongside the staff in the service and guided them to provide the care people needed. This way they were able to monitor practice regularly during the day and ensure appropriate action was taken to address any issues

The manager understood the requirements how to deliver care, treatment and support and embody the culture and values of their workforce and organisation. The manager also kept up with updates in the sector to support their own professional development to ensure they had the skills, knowledge, experience and credibility to lead effectively. The manager encouraged integrity, openness and honesty in the service to ensure any issues or concerns were addressed quickly. The manager and other senior staff were visible to the staff team, people and relatives, and professionals. The manager was knowledgeable about the issues and priorities for the quality of services and told us the changes they have been making since the start of their role. The manager added she felt supported by the provider and senior management to make changes to ensure people continued receiving care and support they needed. The manager added, “[Line manager] is very engaged in the team and knows the home, the staff members. [My line manager] is very hands-on and very very supportive to me. The care quality team is always on the floor, they stay with nurses, and coach them. If anything comes up, they will support the staff. The support team are really hands on rather staying in the office, and tell staff what to do…[Senior management] do not make staff feel uncomfortable”. Staff felt listened to, supported and the manager was approachable. Staff all worked together well and were positive about the leadership in the service that contributed to better outcomes for people, their relatives and staff team. Staff added, “[The managers] are very good. They’re very supportive. They are doing well” and “They check, check, check; and they analyse.”

The manager and staff worked together to promote people's wellbeing, safety, and security and we observed a supportive staff culture. It was clear people who use the service were important to the whole staff team. People and the staff team had good relationships with each other. We also observed staff and the managers were respectful and kind towards people and each other. The manager promoted a positive, caring, transparent and inclusive culture within the service. The staff team were motivated to provide care and support to people as their needs and health were changing. The manager and staff worked positively with people to improve their skills, maintain their health or wellbeing so people could feel they could lead their life as they wished. The manager shared some stories of some big changes in people’s lives and how the staff team achieved better outcomes for people together that had a positive impact on people’s life

The manager fostered a positive culture where people, their relatives and staff felt that they can speak up and that their voice would be heard. The manager said, “Everyone knows the people, and we must support each other…Now there is a home approach here and I am so proud the way we work together and help each other…I told the staff, I do not walk around with manager’s label. I do different tasks, and if you see me do it then there is no excuse for you not to do it. I love what I do”. Staff’s feedback was taken into account to support any improvements. The manager encouraged staff to raise any concerns and promoted the value of doing so. Staff were confident that their voices would be heard, and they were happy to approach the manager for support. There was a culture of speaking up where staff could raise concerns and would be supported, without fear of detriment. Staff told us there was the ‘open door’ policy and the high visibility of senior staff which supported positive culture and relationships amongst staff and senior staff.

When concerns were raised, the manager and provider have investigated those, and lessons learned were shared with the staff team and acted on. Staff agreed the managers were open and transparent with people and relatives if something went wrong, offered an apology and informed of actions taken.

The manager valued and respected diversity in the workforce. They took action to improve where there were any disparities in the experience of staff with protected equality characteristics. The manager continuously communicated with staff and shared any ideas or suggestion to ensure staff were included and were able to contribute to the service. Staff felt positive about the changes in the service and were confident that their concerns and ideas would result in positive change to shape services and create a more equitable and inclusive organisation. They felt supported, treated fairly and looked after by the managers.

The manager valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked at the service. The manager worked alongside staff delivering care so they could understand any issues staff encountered. This approach also encouraged an inclusive and equal workforce and mutual respect amongst staff. The manager used effective and proactive ways to engage with and involve staff, with a focus on hearing the voices of staff. The working environment was inclusive, and staff’s wellbeing was considered. This ensured the service had a positive culture which supported better outcomes for people.

The manager worked to establish clearer responsibilities and roles for the staff team that supported positive changes and improvements in the service. They also had been working on reviewing the service and changes needed to support care and treatment to people. The manager communicated with staff to share information and act on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The manager told us how they oversaw and managed behaviours and performance of staff as and when needed. They also engaged with the whole staff team to ensure they understood the meaning and importance of effective quality assurance and monitoring. This meant the staff team were involved in not only people’s care but also the service welfare and management. The manager said, “Things are happening and I am monitoring to ensure it is embedded. If I do not constantly remind it, that 5 months can be lost, so I need to do it to embed it deeply. I can see the staff are picking it up and doing things, and working with me to achieve the goals I put in place. Staff are happier, and they are smiling. They are a good bunch, and they look after people and they look after each other”. Staff understood their role and responsibilities. Staff were very positive of the changes and improvements made since the new manager came into the service. Staff said, “I feel supported. The new managers who came in are very encouraging, very supportive, ‘hands on’” and “I love my job. I love the residents. It’s because of them that I come to work”. Staff agreed they felt comfortable going to the manager or other management team with any concerns and they would be listened to. However, the evidence we have collected demonstrated the provider did not always ensure there was effective and clear oversight of the service and its quality.

Whilst the governance systems had improved since the last visit, there were still further improvements needed to ensure issues were identified and mitigated using provider's quality assurance system. For example, missing recruitment information for staff suitability and policy did not reflect the requirements of the regulation. Keeping complete and clear records for all premises checks and work carried out. There were discrepancies with medicine management and record keeping. For example, we found some gaps in medication administration record (MAR) sheets and daily checks for medication safety. There were 3 people receiving medicine covertly. The provider’s policy noted this process would only be needed if people were actively refusing medication. When people were given medication covertly, the staff did not always record the rationale for it consistently. Care plans for covert administration needed to have review dates specific to each person and to ensure this method of administration was not overused. The provider had to ensure the service was consistently well-managed and improvements were sustained and embedded. For other areas of the service, the manager had an oversight of the service provided and ensured people received the care and support they needed. They used tools such as audits, spot checks, observations and feedback from people, relatives and staff to monitor, assess and improve the quality of the service. The manager submitted data and/or notifications to external organisations as required. There was an improved emphasis on continuously improving the service and meaningful learning was applied across the whole staff team.

People benefited from the service that worked in partnership with different professionals to ensure people were looked after well. Where necessary, external health and social care professionals had been consulted or kept up to date with developments. The relatives agreed the service worked with external professionals to support people’s health and wellbeing.

The manager understood their duty to collaborate and work in partnership with different stakeholder, so the service worked seamlessly for people. The manager shared information and learning with partners and collaborated for improvements. The manager told us how they worked with people, their families, professionals to ensure people received the care and treatment they needed. Staff agreed things were going well and they were more open and transparent. Staff agreed they collaborate with all relevant external stakeholders and agencies.

Professionals were overwhelmingly positive about the service, the manager’s and the whole staff team’s work so far to make many improvements and to ensure people continued receiving the care and support they needed. Professionals said, “I have observed the culture evolving over the past 8 months at Dormy House, with the team coming together to improve their communication and governance. There is always a warm welcome from all of the team from reception to the care team to the maintenance and catering teams. I have noticed technology being used to aid speedy communication across such a large site and the use of the wireless electronic care records to support the care team in their roles.” Second professional said, “Feedback would be positive in that we feel confident in the manager and the teams in the home now, we do believe that improvements are ongoing and being implemented continually and we will see sustainment”. Third professional, “From our perspective, Dormy Care Home is well-managed. The care home operates smoothly, with a strong focus on the well-being of the residents. The management team ensures that high standards of care are maintained, creating a positive environment for both residents and service providers like ourselves…The staff are competent and responsive, ensuring that the residents' needs are always met”.

Staff and the manager were open and transparent, and they collaborated with all relevant external stakeholders and agencies to ensure they achieved positive outcomes for people. They used a few different systems to report, record and refer people for further support. Staff and the manager encouraged partnership working with key organisations to support care provision, service development and joined-up care, as well as, keeping up with any updates in the health and care sector.

The manager told us how they monitored the service and focused on continuous learning and improvement across the service. As the manager and staff had a good understanding of people’s needs, health and wellbeing, and they were able to identify where improvement were needed. The manager was positive about the reviews completed by different teams which also contributed to the oversight of the service. The manager said, “For me, after all the audits are done, it gives me confidence and comfort that we are doing the right things for people. We hear feedback from people and families…The reports were positive and it gives me more enthusiasm to work even harder”. The manager told us they had and used processes to ensure that learning happened when things went wrong, and from examples of good practice. The manager and provider sought feedback from people and those important to them, staff and used the feedback to improve and develop the service. They also kept in touch with external stakeholders to ensure information sharing was effective and useful to make any changes. Staff had staff team meetings to ensure any items arising from day to day running of the service and others’ feedback were shared with the staff team to ensure smooth running of the service. The manager had an open-door policy and would welcome any feedback of how to maintain a good service. The staff team also used handovers and other daily/weekly/monthly meetings to share any matters, changes and updates ongoing in the service.

Staff and the manager demonstrated a positive, compassionate, listening culture that promoted continuous learning and supported improvements. The manager had established better partnership working with outside organisations. Where necessary, external health and social care professionals had been consulted or kept up to date with developments. The manager proactively worked with the staff team, families and professionals to ensure people were able to achieve their goals and outcomes that had positive effects on people. The service had good links with the local community and the provider worked in partnership with other agencies to improve people's wellbeing.