• Care Home
  • Care home

Starbrook

Overall: Good read more about inspection ratings

35a Dursley Road, Heywood, Westbury, BA13 4LG (01934) 429448

Provided and run by:
Achieve Together Limited

Report from 31 October 2024 assessment

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Well-led

Good

Updated 4 December 2024

We reviewed 7 quality statements for this key question.

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.

Shared direction and culture

Score: 3

Staff felt valued and respected by the provider and colleagues. Staff were aware of the provider values and understood how they applied to their work. Staff felt the culture at the service made sure people were involved and able to live their life as they wanted. Staff also thought the culture was inclusive for everyone.

The provider values were available in the service and on the provider website. Staff were told about provider valued during their induction and any follow up training. There was a registered manager at the service who led by example. Contact details for the registered manager and regional managers were available at the service for staff to contact if they needed. Provider representative also regularly visited the service and spoke with staff to make sure a values approach was embedded.

Capable, compassionate and inclusive leaders

Score: 3

Staff knew the registered manager and said they were approachable, inclusive and willing to help them when needed. Staff thought the service was well-led. One member of staff said, “[Registered manager] is very approachable. I feel they model inclusive behaviour and they are really fair.”

The service had a manager in post who was registered with Care Quality Commission (CQC). This meant in addition to the provider recruitment process the registered manager had also completed the CQC fit person process to become registered. There was a regional manager in post who visited the service regularly. They facilitated regular ‘managers meetings’ with other services they were responsible for. This enabled the managers to network with each other and provide peer support.

Freedom to speak up

Score: 3

Staff were aware of the whistleblowing policy and process and felt they could raise concerns easily.

The service had a whistleblowing policy and various ways staff could raise concerns. The regional manager visited regularly and was available for staff to speak with. There were also links to raising concerns on the provider website.

Workforce equality, diversity and inclusion

Score: 3

Staff worked in a service which promoted equality, diversity and inclusion. For example, staff experienced support to help them pray or have time off for religious or cultural events.

Staff had training on equality, diversity and inclusion and a range of policies and procedures which provided guidance. There were various support groups available for people and staff, information on these was available on the providers internal intranet system. The provider reviewed any requests for reasonable adjustments and tried to accommodate needs and requests wherever possible.

Governance, management and sustainability

Score: 3

The registered manager had an overview of all quality and safety checks being completed at the service. They told us the provider had various electronic systems available to help them with oversight which they were still learning to use. The registered manager told us, “We have a new system where all the documents get uploaded. It automatically generates timeframes and is a good system. I get a good oversight of where we are in terms of documentation, that includes medical reviews, health checks, all of it is on the system.” The regional manager visited regularly to support the registered manager with their learning but also to carry out their own checks on quality and safety.

The provider had a range of quality and safety checks which were completed as part of their governance of the service. Checks were completed by staff, management and provider representatives to make sure there was good oversight. Regular surveys were completed for people, relatives and staff to gather feedback on what was going well and what could be improved. All results from quality work were added to a ‘home development plan’. This recorded an overview of results from surveys and outlined objectives for the year.

Partnerships and communities

Score: 3

People and relatives, we spoke with did not raise any concerns about how management worked in partnership with them and others.

Management was aware of local health professionals and told us they regularly liaised with them to improve health outcomes for people.

Professionals we contacted did not share any concerns about this service.

The provider and the registered manager understood the importance of partnership working and engagement with local stakeholders. The service regularly consulted with health and social care professionals to enable the service to respond to people’s needs. Systems were effective in making sure referrals were timely.

Learning, improvement and innovation

Score: 3

Staff were able to share their ideas for improvements and developments to the service. One member of staff told us, “There is always a chance to raise concerns or share ideas in team meetings. I can also walk into the office, I feel heard, and I feel valued. I feel staff are viewed as a big part of Starbrook.”

The service was supported by the provider and had links with other services nearby. Regular management meetings were held where good practice and learning was discussed. Any ideas for ways of working that would improve outcomes for people were shared.