Cloverdale

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

We assessed 7 of 8 quality statements within the well-led key question. At our last inspection published 28 October 2019 this key question was rated outstanding. At this assessment the rating has changed to good. During our assessment of this key question, we found systems and processes were in place to identify challenges, areas for improvement and share learning. Also, staff felt listened to and received regular supervisions and were able to raise concerns. However, a lack of visibility of senior leaders, a consistent staff team and gaps identified in some staff’s knowledge were identified as concerns. Leaders had themselves identified these areas of concern and were taking action to improve prior to this assessment.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Some staff told us they felt a lack of motivation due to the stress of work and completion of paperwork which was expected in line with requirements. For example, staff were required to sign to confirm they had read people’s updated care plans and not all staff had done this. This meant staff may not be aware of people’s current needs and how to support them. A staff survey had been completed with mixed feedback. This included staff felt there was an open culture which was well led. However, not all staff felt senior leadership demonstrated the values and not all would recommend the service. Leaders had worked with staff to drive improvements in culture, however recognised further work was required. Leaders told us a focus had been on working with staff to complete required records and the quality of handing over information, also driving a shift in staff culture, however leaders stated the staff culture was an ongoing plan. In addition, staff confirmed they received regular supervision meetings and coaching when required and there were debriefs available.

The provider’s statement of purpose set out the vision and values which underpinned people’s care. Staff and leaders confirmed staff had access to relevant guidance and supervision to allow staff to express themselves.

During the inspection process, the registered manager resigned leading to the service being managed by the regional support manager. Plans were in place for this to continue until a new manager had been recruited. Staff feedback from the staff survey included they wanted senior leadership to be more visible within the service which leaders acknowledged and told us they would take action. Leaders told us regular staff and senior staff meetings were held and described allocating more responsibilities to senior staff, however recognised there were gaps in their knowledge which required additional training.

The provider had processes in place to induct and support new managers, which included support from the regional manager and oversight by the operations manager. However, the manager still resigned, which was the second manager to resign within 6 months. This was discussed with the provider who were reviewing their systems and processes in response. The provider did have a process in place to ensure there was an interim manager in place immediately which in part, mitigated the risk to people who use the service.

Staff knew how and with whom to raise concerns and were confident if they spoke to the management team, action would be taken. Throughout the inspection, the management team were open and transparent and described how they promoted an open culture where they wanted people, their relatives or staff to raise any concerns, so they could look at ways to resolve them. Leaders told us staff had completed stress risk assessments, however only one staff member had raised concerns.

Policies and processes were in place to enable staff to speak out. There was no evidence of closed cultures though leaders described maintaining an open culture as an ongoing process they were working with staff. The provider carried out staff surveys and analysed this information to be able to act where needed. They were open and transparent about any areas needing improvement and took prompt action to do so.

All staff felt they received regular feedback to support their growth, and the manager was fair and would listen to them. All staff we spoke to told us they felt policies and procedures were fair, however staff gave mixed feedback in a staff survey regarding levels of pay received. Most staff we spoke to did not express any concerns about equality and diversity and said they felt the company valued diversity. Staff told us they understood what to do should they witness discrimination.

Processes were in place to promote a diverse workforce. This included staff surveys and regular supervisions to allow staff voice to be heard and regarding staff’s health needs. For example, evidence was seen of a pregnant staff member having a risk assessment in place which was regularly reviewed and updated. This also would apply to any underlying health conditions and a policy is in place for staff and leaders to follow.

Leaders told us they understood the challenges within the service and had identified areas for improvement confirming work was ongoing. These areas included reviewing auditing processes, reviewing care plans, improving the culture within the service and recruiting suitably qualified staff to the team. However, the manager and leadership team were aware of the current risks and there was a significant number of actions to address. In order to deliver the required improvements for people, they were working through these. Leaders were able to describe the systems and processes in place to enable oversight of the service.

The provider had audit processes in place, for example, the manager told us they audited the service every 3 months with any actions identified being added to the service improvement plan along with audits for staff files, medicines and people’s care plans. However, the provider had identified the auditing process required updating to enable a greater focus on specific issues. Surveys with people and their relatives and staff had been completed in the last year. We saw the analysis of these surveys, which showed action was taken in response when areas of improvement or learning were identified.

People we spoke to told us they felt listened to and staff would help them if needed. One person told us, “if you were concerned or felt unsafe, staff would listen to you.” When people’s needs changed, appropriate referrals were made to external professionals. For example, one person’s needs had changed, and a referral was made to commissioners to discuss funded support hours which would improve the persons experiences.

Staff we spoke to told us they felt they worked well with other agencies. Staff also told us of the impact of staffing levels and lack of transport and how this could limit people’s opportunities. Leaders told us they were aware of this concern and were recruiting staff to resolve this issue for staff and people and their families, as well as the manager advocating on behalf of people who use the service and their care needs. Leaders told us they had recently met with the local authority following incidents within the service to review them. Following this learning was shared with staff.

External professionals spoke positively about the staff and management team. One professional told us the service was open and transparent.

Processes were in place to ensure any issues identified for people were raised with relevant professionals. For example, when one person’s needs changed, the management team had appropriately requested a review by external professionals due to the impact on other people within the service.

Following recent incidents within the service, leaders had met with external partners to review them and allow learning to be shared with the staff team. Leaders were working with and supporting staff to improve in this area. Some staff told us information was communicated through a communication book and they felt more could be done to ensure information is communicated to them effectively.

Processes were in place to review safety incidents, identify areas for improvement and share learning. For example, following a recent incident, staff had updated their training, reflected on the incident and taken learning points as individuals and a staff group. In addition, when a serious incident had occurred, we viewed an investigation report which showed it had been investigated independently from the service by the investigations manager. Actions had been identified and added to the service improvement plan.