Greenacres Grange

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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

During our assessment, we have identified a breach in relation governance. We assessed 1 quality statement in the caring key question and found areas of good practice and concerns. The governance systems in place had failed to identify issues with medicines management and poor-quality care plan documents. This meant that the processes in place were not effective and did not provide assurance about the governance or support good management of the home. There was a clear management structure, and accountability arrangements. Staff understood their role and managers accounted for the actions, behaviours, and performance of staff. Notifications were consistently submitted to external organisations as required. There were arrangements in place to ensure the confidentiality of data and records. Information was not consistently used effectively to monitor and improve the quality of care. Leaders kept up-to-date with best practices to improve outcomes for people using services. We have asked the provider for an action plan in response to our concerns.

This service scored 7 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

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 had addressed a number of issues which included workforce planning. They told us, “The most important thing to me was feedback from relatives about all the different staff and no continuity. I have recruited more staff and try to keep the same staff on. Staff bond with residents and families, it’s so important.” The provider had recognised a need to implement a more robust management structure to support the governance, management, and sustainability of the service. The operations director told us that each home has a manager, a deputy, and a clinical lead and they were in the process of recruiting a clinical manager to support across the group.

The provider had implemented a new electronic care planning system to improve management oversight and both the registered manager, and the quality and compliance manager carried out auditing processes at the home to check they were providing good quality care and support. However, the systems in place had failed to identify issues with medicines management and poor-quality care plan documents. This meant that the processes in place were not effective and did not provide assurance about the governance or support good management of the home.

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

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.