Saffron House

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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

We assessed a limited number of quality statements in the well led key question. The scores for these areas have been combined with scores based on the rating from the last inspection, which was requires improvement. The provider had developed more effective governance arrangements to help identify shortfalls and drive improvements. We found improvements had been made in areas such as medicines and infection prevention and control. However, further improvements were needed to ensure care and support was delivered in line with evidence based practice and standards. We observed improvements were not yet fully embedded in staff working practices. Records relating to people's care were not always fully up to date or completed consistently to evidence the care provided. Work was in progress to update people's care plans. Staff spoke of an improved, positive culture within the service and of a sense of trust and confidence in the skills of the leadership team who they felt were visible within the service, supportive and made them feel valued. Staff told us they were encouraged to raise concerns without the fear and team meetings could be used to share suggestions or ideas.

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.

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.

The registered manager was new to the service. Staff told us they believed in the new managers ability to lead. One staff member said, “Things are better here now. There is more monitoring and everything is more professional.” Another staff member told us, “Things are better now after all the changes with management. We had become complacent, and things were overlooked. It’s not perfect but we are getting there.”

The provider had made changes within the leadership of the service and provided support and oversight to support improvements to be made. At the time of our assessment visit, the registered manager had begun to improve the support to the staff. The registered manager raised notifications in line with regulatory responsibility and understood their duty of candour. Apologies were made when things went wrong, and complaints were acted upon.

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.

Staff told us they understood their responsibilities and duties. However, we observed variances in staff approach and skills and found staff to be focussed on completing tasks resulting in missed opportunities to interact with people. The registered manager agreed more work was needed to record how staff interacted and provided person centred care and told us this had been identified and work was in progress to drive improvements

A range of quality audits were taking place including safe handling of medicines, health and safety and care documentation. We saw evidence of improvements as a result of increased oversight from leaders, monitoring and interventions. Improvements included health and safety and safer medicines management. Improvements around staff deployment, staff skill set and approaches and activities remained in progress at the time of our assessment visit. The registered manager was committed to driving improvements within the service and developing a positive, supportive culture for staff.

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.

The registered manager and provider’s representative told us they were focussed on learning and improvement and developing a positive culture in the service. They acknowledged this had not always been the case. Managers were implemented more observational supervision for staff and were reviewing care plans and records which was in progress at the time of our assessment. The provider had identified areas which required improvement prior to our assessment and we found improvements had been made, identified or were in progress at the time of our assessment. The registered manager and staff acknowledged further improvements were needed but felt the service was moving in the right direction. There was a clear enthusiasm and commitment from both leaders and staff to providing people with good outcome from their care and support.

The provider had learned lessons from previous incidents and concerns. For example, they had reviewed their admission processes and criteria to ensure they were able to meet people’s needs safely. Trends and patterns were analysed, and lessons learnt were shared appropriately. The registered manager was aware the implementation of best practice was not always adhered to through staff working practices. They had implemented increased oversight and supervision and reduced the use of agency staff to begin to address this.