41 West Hill

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

Improvements had been made to the governance, management, and accountability arrangements. Staff understood their role and responsibilities. Managers accounted for the actions, behaviours, and performance of staff. There were arrangements for the availability, integrity and confidentiality of data, records, and data management systems. Information was used to monitor and improve the quality of care. The systems to manage current and future performance and risks to the quality of the service did not always take a proportionate approach to managing risk that allowed new and innovative ideas to be tested within the service. Leaders did not always ensure relevant or mandatory quality frameworks, recognised standards, best practices were applied to improve equity in experience and outcomes for people using services and tackle known inequalities.

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.

Staff and management showed a shared commitment and passion for the direction they wanted 41 West Hill to move towards. They were committed to making the necessary changes to ensure people received good care and support. However, the provider did not explain how and when they were going to achieve their vision. Staff had regular contact with the management team. Staff meetings had been undertaken to ensure that staff were involved and understood the shared direction and the changes to the service. We found a significant culture change in how staff responded to people who showed signs of distress or agitation. A staff member told us, “After the last CQC inspection, we had a staff meeting to discuss the changes that needed to be made. Staff have also had opportunities to say what needed to be changed. We have worked together and now people are safe. We now use more distraction techniques and know people better to see people’s early warning signs.” Another staff member told us, “We have supervisions and team meetings, and we have discussions, and we are able to understand the changes and asked for our opinion. We didn’t have that before.”

The provider was able to describe a clear vision, and this had been shared with the staff team. However, there was no strategy or plan in place on how their vison was going to be achieved. The action plan that was in place was a response to concerns and risks identified by the CQC or the local authority. Therefore, we were not assured that there was a clear process for shared direction. The provider and management team worked hard to build an open, positive, and listening culture with relatives. The provider was committed to learning and improving from where things had gone wrong.

Staff told us the new registered manager was capable, compassionate and an inclusive leader. One staff member told us, “The new manager has really done a good job and brought a lot of positiveness into the home, staff are able to speak to her openly. She really respects your opinion. I feel so much happier going into work. Since the CQC inspection and a new manager the service is much better for the people living there. The new manager empowers you and even if we have completed training, she will show you, so you know how to do it, for example medicines I feel much more confident because she has explained it and showed me. The provider is much more involved, they are kind, and we have better communication with them and a lot more accessible to us now if we need them.” Another staff member told us, “I have to say the new manager is really nice and she has put a lot of things in place. She gets things done. People are getting a lot more choices, more activities, and a lot more to do around the house, pool table, trampoline. We have some brilliant staff, and they do a lot with them. The staff team get on well, we have a laugh. The staff team works well and help each other, and this is down to the manager.” The registered manager spoke positively about the support they have had from the provider and felt all the senior managers were capable and compassionate about improving the service to ensure people received safe quality care and support. The registered manager told us the staff have been on board to make the necessary changes and acknowledge further work was needed but they had not had enough time to put everything they wanted in practice. Their main focus was to make the service safe for people.

The service was led by compassionate leaders. A new registered manager had been recruited since our last visit. The provider worked with an external consultant to support their knowledge to improve the service to meet CQC regulations. The registered manager was clear about their role and submitted notifications in accordance with regulatory requirements. The management team responded to all concerns raised during this assessment. However, identified concerns from our previous inspection and the local authorities visit had not all been completed, for example ensuring the principles of the Mental Capacity Act were followed. We also raised further concerns over restrictive practice that had not been identified by the provider or the management team. Therefore, we were not assured the management team were always able to ensure their practices met best practice guidance. Staff had completed relevant training and were aware of their role and responsibilities. The provider visited the service regularly to ensure that certain tasks were completed. Their visits were logged, and clear records were kept of the discussions held and any actions identified.

Staff felt they had the freedom to speak up. One staff member told us, “I feel much more confident in speaking up more. There is much more equality within the staff team. Before, we didn’t feel equal and able to speak up. When I have raised issues, the register manager is not biased, and she has taken action. The new manager will listen, and she keeps things confidential where needs to be, which I respect.” The registered manager told us they have an open-door policy and staff have been told they can contact them anytime. The manager starts work before the night shift staff finish to allow night staff the opportunity to speak with them if needed.

There were effective processes in place for staff to feed-back and speak-up through staff meetings and 1 to 1 supervision with staff. The registered manager had an open-door policy. The provider had ensured they had shared their contact details to allow staff to speak up to them if needed. Staff were aware of the whistle-blowing policy.

The staff team felt the culture of the organisation ensured equality, diversity, and inclusion. One staff member told us “Yes, I feel equal, and much more included in the home than I ever did before. This has improved since the new manager and now we work much better as a team. She [the registered manager] ensures we are all included.”

The provider had a policy in place for Equality and Diversity. Staff had completed equality and lesbian, gay, bisexual, and transgender (LGBT) training. The new registered manager was working on the culture of the home to ensure all staff felt valued, respected, included, and listened too. During staff meetings, staff were encouraged to talk about their ideas and share their concerns. Staff working at the service were from different backgrounds, the registered manager empowered people to be proud of their culture and ensured everyone was treated fairly. All staff had the same rights and opportunities. There were processes in place to protect staff from bulling at work. Pay was equal, the provider ensured pay was based on job roles and not gender.

Staff told us the new manager was approachable and had made changes to the service which has resulted in people having safe care and improving their care outcomes. Staff felt the new registered manager had a better oversight of the service. One staff member told us, “The new manager is really good and has us now working as a team. We can raise anything, and she will take action.” Staff were unable to explain what plans were in place to further improve the service to ensure people received person centred support to develop their skills and understanding for a more independent life. Staff told us they were not aware of any plans in place to make any other improvements but were committed to work with the provider to ensure people had the best care possible.

Improvements had been made since our last visit to the governance process. For example, accident and incidents were reviewed by the registered manager and they completed a monthly review, with the aim to reduce incident and learn from them. However, due to the length of time the new registered manager had been in post, not all audits had yet been completed. For example, health action plans and care plans had not had a management audit since our last visit. Therefore, we were not assured that the governance system and process was always effective at identifying concerns and risks. The management team had worked hard to make changes to ensure people were safe. However, staff at all levels were not always demonstrating their understating of equality and human rights. People had restrictions in place that had affected their human rights and the provider had not ensured the restrictions placed on people were regularly reviewed to ensure they were always needed and if they were the least restrictive options. The provider had an action plan in place to address concerns from partners. However, we were not assured the provider had effective processes in place to ensure they could identify concerns and risks within their own systems. For example, findings our visit had not been identified by the provider’s systems, processes, and management. The provider had emergency contingency plans in place should there be an event that could affect the running of the service. The provider had implemented a quality assurance system. People and relatives were asked for their feedback.

We saw an improvement in people accessing the community and engaging in more trips. Relatives told us they felt the management team were working better with other partners and acted on concerns raised. Relatives spoke positively about improved partnership working. They felt significantly better communication had resulted in positive outcomes for their loved ones. One relative told us, “Since the CQC visit and the changes that have happened, it's so much better and we are seeing the difference. They[management] now make effort to communicate with us.”

The management had been working with the local authority and they visited once a month. A manager told us, “We value their visits, it’s been helpful, and we ensure we action any of their actions and recommendations.” Staff told us since our last visit, people were accessing the community more, people were visiting pubs for food and local swimming centres. Staff and management told us they were exploring and trying to find more options for people to be part of their local community.

The provider was working openly with the local authority to make the necessary improvements to meet their contractual obligations.

The provider had a good process in place to work collaboratively with all health and social care professionals. Care plans demonstrated relevant professional input on how to support people with their health care needs.

The management team told us they had reflected and learnt where they went wrong. One manager told us, “We have encouraged staff to think out of the box and where can people access to give them even better outcomes. We did a staff activity where we got staff to find 3 other activities. We found that staffing for 1 person was not correct since the commissioning hours increased, we were able to do a lot more and this has had a positive outcome, with more access to the community.” Staff and management did not explain what innovation was taking place to create and encourage more equality, experiences, outcomes and to increase the quality of life for people. The management team told us they were aware further and learning and improvement was needed. They were committed to ensuring this would take place and be imbedded into the culture of the service. However, there was no clear plan in place to demonstrate how they were going to achieve this.

Improvements were needed to imbed a culture of continuous learning, improvement, and innovation. The provider was proactive at taking action when required improvements were highlighted through CQC and other partners. However, there was a not a holistic system or processes to focus on continuous learning and improvement internally. The service was not always actively aware of safe, effective practice and research. We did not see a process or systems for continuous improvement and innovation to try new ways of working to ensure people were receiving care in line with good practice guidance and always ensuing their practice was the least restrictive practices. The provider had plans to move onto an electronic system for care planning and daily recording to further improve their record keeps and oversight.