Rotherlea

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

At the last inspection, we found the provider in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulation Activities) Regulations 2014. The provider had not always assessed, monitored or improved the quality and safety of the service provided. At this assessment, improvements had been made and the provider was no longer in breach of regulation 17. Improvements had been made in the ensuring staffing levels were appropriate and continuously reviewed to reflect people’s needs. The registered manager had worked to promote an inclusive service, improved the culture of the home and improved oversight of care through consistent and robust quality assurance systems. People and staff spoke positively about the registered manager’s approach.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager showed a focused approach in improving the culture of the home and providing a positive approach since their appointment. Equality and Diversity training was in place for all staff to complete as part of their core training and completion compliance was high. The registered manager understood the risks to delivering strategy and had used audits and actions plans to address them. The provider had followed their action plan following the last inspection to implement necessary changes and improvements to areas such as staffing, Accessible Information Standards, and making the senior leadership team more visible and open to staff. Records showed that consistent and regular supervisions and appraisals were undertaken, while inclusive staff meetings were held so staff could provide feedback and contribute.

The registered manager was knowledgeable about issues and priorities for the quality of care at the home. They appeared engaged, relaxed and confident with people living at the home. Leadership was sustained through safe and effective recruitment. Staff could access support and development in their roles. The promotion of staff development was a focus of the registered manager. All Team Leaders were working towards NVQ or held the qualification. The registered manager stated that, at present, "18 - 20 staff could be in management roles."

Staff spoke warmly and positively about the registered manager. One staff member said, “My manager is very nice. He helps us on the floor. If there is any problem, he will talk to us. He will ask me how we are and if we are ok. He's very approachable. Most of the people here feel that way because he's very kind. Some staff say he's the best manager we have had.”

The registered manager was knowledgeable about issues and priorities for the quality of care at the home. They appeared engaged, relaxed and confident with people living at the home. Leadership was sustained through safe and effective recruitment. Staff could access support and development in their roles. The promotion of staff development was a focus of the registered manager. All Team Leaders were working towards NVQ or held the qualification. The registered manager stated that, at present, "18 - 20 staff could be in management roles."

The registered manager had showed a focused approach in improving the culture of the home and providing a positive approach since their appointment. The registered manager confirmed that the service had not received any whistleblowing alerts during his period as registered manager. CQC's own records confirmed this. Staff receive full information about whistle blowing within their induction packs. The service displayed posters for staff with information about how to raise any anonymised concerns on the provider's online portal. Staff had been invited to complete an anonymised engagement survey; results were positive and engagement percentage was high. The leadership team has carried out consistent and regular supervisions with staff to ensure that their views and feedback were heard. Monthly staff meetings held with those being unable to attend the home can participate on Zoom. Information about how people can raise concerns are discussed directly with them when they arrive at the home.

Feedback form staff was positive in their ability to discuss issues openly and to feedback any concerns. One worker said, "Management is really open. They say you can come to us if you aren't happy."

The registered manager had worked towards greater inclusion of staff in decisions and providing upskilling opportunities. Many staff were flexible to and able to undertake dual roles. Activity and domestic staff sometimes covered as support workers when needed and had received full support worker training. Staff were able to cover should there be increases to people's needs. The registered manager confirmed that there were currently no staff employed with protected characteristics or required workforce adjustments. The providers equality policy had procedures and guidelines for leaders to follow to ensure that adjustments and considerations should be made if needed. The providers Equality and Diversity policy included protections and procedures, guided by law, on ensuring workforce equality in opportunities and treatment. Staff's wellbeing was actively promoted and supported by the registered manager and provider led policies. Staff had access to Occupational Health if required, while the provider ran a scheme with a GP service for those staff who were experiencing difficulties accessing their own GP. Monthly staff meetings held with those being unable to attend the home can participate on Zoom. The home ran a free return transport service to Bognor and Chichester for staff. The registered manager indicated that this was a crucial resource given the remote location of the home. The provider is employee owned and the service has an employee representative who attended the Employee Work Forum. Staff are able raise issues and provide feedback about the business.

Staff were clear that they felt they were treated equally and with respect by the management team. They felt opportunities were available to progress if they wished and that management would support them in achieving this. One staff member stated, "Yes I believe Im am treated equally."

There was a clear management structure in place, while staff understood their own roles and responsibilities well. The registered manager engaged positively with their Deputy Manager throughout the inspection and was clear in the divide and responsibilities of their senior roles. Quality assurance systems were in place to maintain oversight of peoples support and improve performance. Quality checks on areas such as infection control, medication, falls, health and safety and food quality were completed regularly, while the provider conducted monthly audits in different areas of the service. The registered manager used these audits to drive improvement. For example, people’s dining experience had been an area previously highlighted as requiring improvement. Reviews of what people wanted as well as audits had created a far more positive experience for people and staff to work in. We reviewed the providers Contingency plan and policy which was detailed in its preparedness for unforeseen emergencies. A review of statutory notifications as part of the assessment showed that leadership were clear and prompt with their regulatory requirements. Statutory notifications are events that the provider is required to notify CQC of. Confidential information relating to people at the home was held securely with protected digital systems or locked cabinets when in hard copy. The registered manager was diligent in ensuring that requests for information were cleared by the providers Compliance Team before sharing. Staff undertook training on General Data Protection Regulation (GDPR).

The registered manager stated that the providers Compliance Team contributed to his oversight of quality at the home, while supporting him in improving reporting mechanisms. The registered manager said that the Compliance Team undertook two full home inspections per year and that the home was currently at 96% compliance. Feedback from the registered manager was positive and they stated that he had an ongoing drive to make improvement to systems. For example, despite currently having oversight on data relating to call bell responses, he was working with the provider to develop improved systems to capture more detailed information. The registered manager commented on the consistency of the quality assurance systems by saying, "Care plan audit are always in depth and always generate actions. Medicines audits are what has helped us get to the position we are now."

People benefited from the collaborative relationships staff at the home had developed with external professionals and services.

In respect to sharing good practice, the registered manager talked positively about the support and partnership with other managers of Shaw's homes. The registered manager said, "I have lots of collaboration with other registered managers. We know each other well in West Sussex."

Feedback from professionals and partners was very positive on the engagement and professionalism of care staff and management. One professional said, “The entire team are very committed to high quality care for their residents.” “Both (registered manager and deputy manager) are clearly very approachable to their whole team and are a visible and constant presence throughout the whole care home with a lot of hands-on involvement. They added, “I am so incredibly impressed by the way in which Rotherlea is run and provides care for its many residents. This opinion is shared by the rest of the team, who also have significant amounts of contact with the care home.” Another professional said, “They have always been easy to contact and communicate with and have always been professional in how they have managed sensitive topics/conversations, particularly with complex end of life care. I have found (registered manager and deputy manager) both very proactive in managing complex patients and supporting families.”

The provider and registered manager had utilized the specialist support provided by professionals outside of the service. Appropriate referrals for specialist and health support had been made in a timely manner and guidance was incorporated into people's care plans and support. Engagement and referrals had been made with professionals such as SaLT (Speech and Language Therapists), Community Nurses, GP surgeries, Opticians, MH support and Palliative Care. The registered manager spoke of some challenges with information sharing and response with some partners when people had been admitted to hospital settings. The registered manager was positive and continued to look to improve these. The inspector observed a reception for a service user who had been discharge from hospital without notice. Staff were available to facilitate effectively with the support of the registered manager. The home had good community links in place, despite the remoteness of the service. Links with a local school where students attend the home and do choir singing and play games with residents. Seaford College undertook a community action day at the home with residents.

The provider considered the introduction of technology to further improve people’s support. Since the last inspection the provider had introduced handheld electronic devices to allow staff to record the support they provided. As well as staff stating that this allowed more time to spend with people, the registered manager said that this introduction had, "Improved my ability to have oversight. Its's easier to do reporting at the point of care." The registered manager said, "We've checked off compliance and making things safer, getting to a point to encourage staff to do more person-centred recording which we are supporting staff to write. Wellbeing is what we are looking at now. We have the basics right now, and now we will go a bit further. It's been a journey shall we say. The last year has been about improving moral and client satisfaction."

The leadership team had a consistent approach to making improvements. Since the homes last inspection, further improvements had been made and embedded. The provider had completed a detailed action plan since the last inspection and made improvements to how it assessed staffing levels according to need and implemented these. Deployment of staff throughout the large home had been considered by the Registered Manager and was flexible in their approach and adaptable to changing deployment when required. There were processes to ensure that learning happens when things go wrong, and from examples of good practice. For example, the provider had reviewed a key policy following a death at the service. Although there were no concerns about the support provided and the actions of the provider, the provider used the opportunity to review and improve areas around supporting people who declined support.