Tanglewood Mews

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

The service was not always well led we found a breach of regulation regarding leadership, records and processes. Staff felt supported by management. The organisational culture was not always person centred. Processes in place to manage the service were not always effective or robust.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service was in the process of recruiting and making improvements to the staff team. We received mixed feedback from staff. One member of staff told us," The manager is approachable, morale could be better there is a high staff turnover." and "Morale is good, it's getting there".

The Strategy and vision of the provider was not always clear. Organisational culture was not always person centred and was not meeting the registering the right support right care right culture best practice Values. The processes in place were not always enabling the registered manager to respond in person centred ways.

Staff told us the registered manager was approachable and supportive and they had no issues in contacting and seeking support from them. However, some issues found on inspection were not being addressed.

There had been some changes in management arrangements. The new registered manager had been in post over 6 months and had implemented improvements and made changes. They understood where gaps in practice had been and were addressing these issues. However processes in place didn't always enable the manager to have good oversight of the service.

Staff told us they felt confident to raise concerns with the provider and these would be listened to and acted upon.

The service had a whistle blowing process in place that was used by staff.

Staff felt they were valued and the staff team was inclusive and diverse.

The provider valued diversity and followed best practices guidance.

Quality assurance took place from questionnaires with family members but this wasn't being carried out with people who use the service.

Process in place regarding managing incidents were not robust or effective. Roles of the registered provider responsibilities and accountability were not always made clear and there was a lack of engagement with people who use the service. Statutory and regulatory requirements were met regarding notifications being looked at outside of assessment process. Records/digital records in place were not accessible the manager was unable to produce records during the inspection or following in a timely manner. Obtaining the training records for staff was difficult and there was no over sight.

People had regular access to healthcare professionals.

Staff told us they worked closely with healthcare professionals and received training from them where necessary.

People had access to and staff worked in partnership with external agencies and where appropriate shared information and learned with them.

The service worked together with other healthcare professionals and in partnership with the local authority commissions on improvement plans.

Learning and improvement staff meetings took place regularly and, workshops focusing on lessons learn from within the provider.

There was a process in place for staff to ensure continuous improvement through learning was achieved. Creative ways of delivering care were not always explored.