Downhurst Residential Home Limited

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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 6 quality statements in the well-led key question. We found the provider had a good effective system in place to check the quality of care. People, staff and relatives were asked for feedback on a regular basis. The provider had an improvement plan in place. People and relatives told us they could make a complaint if needed and it would be addressed.

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.

Staff told us there was an open and transparent culture. Staff were able to share their concerns through one to one meeting or team meetings. This meant they could seek advice and support when needed. Staff and the registered manager had a clear improvement plan for the service. Staff were aware of the shared goals for the service.

The provider shared their values and vision for the service with the staff team. The management team promoted an open culture.

The registered manager promoted staff training and development. The provider provided staff with training to assist them in their role. Staff competencies were checked regularly. Staff told us they felt well supported in their role.

The registered manager told us they had undertaken additional training for their role. They also shared with us that there was a new structure in place which was assisting the service to move forward and make improvements. Feedback from everyone we spoke with was very positive about the management team.

All staff we spoke with told us they were able to speak up and were not fearful of any repercussions. Staff told us they had multiple opportunities to offer feedback to the management team. Staff were able to explain the importance of whistleblowing.

The provider had a process in place to encourage people to speak up and raise their concerns. The process was clear and transparent. Whistleblowing policies were in place. This meant staff had guidance when needed.

The registered manager told us the staff working at the service reflects the diversity of the people we support. We value, understand and respect different cultures across our workforce. Staff had been given a questionnaire which included questions on equality however, at the time of the inspection the results had not been received. Staff had regular one to one sessions and team meetings. This meant they could raise issues at any time and seek guidance and advice.

The provider had equality and diversity policies in place. Staff had training in equality and diversity. This meant staff had guidance available to them when needed.

The registered manager told us they had a robust system of audits in place which focused on the quality of care. Action plans were in place to improve the service.

The registered manager and senior managers have effective oversight of information used to monitor and improve the quality of care in line with quality frameworks and recognised standards. Examples of audits and actions showed there was a consistent approach to delivering high standards of care.

The provider worked with the funding authority and health care professionals. This enabled the provider to provide better care and support. People could then achieve better outcomes.

The registered manager told us they were committed to working in partnership with other relevant parties. For example, the GP visited the home on a regular basis. This meant people’s health needs were prioritised and referrals could be made to other professionals swiftly. In addition, the registered manager was involved in peer meetings across the local area. This helped in terms of sharing experiences and challenges with other registered managers as a way of seeking support.

Over the last 6 months the provider had worked closely with the funding authority. The funding authority told us there had been several improvements made by the provider to meet regulations and engage with them.

The provider could evidence how they worked in partnership with other services and professionals across the community.

The registered manager told us they were open to learn and make changes to improve the service. They stated they had more training and a new management structure had been put in place which enabled the registered manager to focus more on the home and push forward with the improvement plan.

The provider had taken on board feedback from relevant parties and as a result had made a number of changes to the service. Improvements had been made in several key areas, for example, staff had more training, the way medicines were managed had been changed to ensure it was more accurate. A new quality assurance framework was put in place to ensure that audits of the quality of care were more robust. The home had consulted with people and relatives about re-decoration and refurbishment of the home. All these improvements meant people could live in a home which better suited their needs.