LJ Sure Mercies

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 registered manager had a strategy for the future growth of the organisation. Her vision was to grow the business slowly so as to retain the highest quality of care possible. The service was only supporting a small number of people at the time of the assessment and had been working towards developing partnerships with other professionals. At the time of the assessment we were unable to get any useful feedback to support the assessment. Staff told us they felt valued and embraced the culture, vision and values of the organisation. One staff member told us “Our manager is so good, she really supports us well, calls in to make sure we are ok and often rings to check on our wellbeing”. Another staff member told us “The manager knows about people’s needs, she rolls her sleeves up and provides the care herself. She can then assess any changes to people’s ability”. Staff told us they embraced equality and inclusion in the service. People and staff alike were treated as individuals and respected for their contribution. Staff told us they had regular meetings and individual supervision with the manager. They felt able to speak up and felt listened to. The registered manager had well established systems and processes in place to ensure the smooth running of the service. Regular quality assurance audits were completed. This included audits relating to documentation, care plans, risk assessment, and daily log notes. Quality assurance audits were completed frequently. Any constructive feedback was used to making improvements to the care people received. The registered manager had a business continuity plan. This included how to grow the business in a sustainable way, to remain competitive and quality focus driven.

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.

The registered manager and staff told us they worked together to ensure people’s needs were met. Family members told us, the registered manager was very involved in the care people received and was always available. One relative told us, "The registered manager is very hands on. We can contact her and office staff at anytime on their mobiles with any queries or requests. They always answer on the same day and have never objected or refused any requests we have made. They have always been very friendly and helpful." Staff told us that the registered manager was supportive and was available if they had concerns or questions.

People were cared for by staff who followed systems and processes, this included having clear guidance about what was expected of care staff when providing care and if for example they were running late. The registered manager told us about their plans for the ongoing improvement of the service, they told us, " We want to build from a robust structure in bite sized chunks to ensure the quality of care is maintained throughout the service."

Staff told us they felt supported by the registered manager and office staff. Staff felt the management team was open and approachable.

There were processes in place to ensure the registered manager had the necessary skills to carry out their role. The registered manager told us they were proactive in attending training which was run by the local authority and by attending other regular external training.

Staff understood they could raise concerns and share information if it was positive or negative. Staff were aware of the whistle blowing policy, and how to report any concerns. The registered manager told us, there had been no concerns raised but " Whistleblowing is discussed in team meetings and we have explained the action staff need to take if concerns are identified."

There were systems in place to ensure if staff wanted to speak up, they would be protected from any type of discrimination. Staff were aware of the right to share any concerns both internally and to elevate externally if they felt they were not being taken seriously.

Staff told us the service was a good place to work. The registered manager introduced an employee of the month and they told us this was positive for the staff team.

The provider’s equality and diversity policy gave a commitment to ensure that people using the service and staff with any of the legally defined protected characteristics did not experience inequality or discrimination. Protected characteristics are specific aspects of a person's identity defined by the Equality Act 2010 which includes protection from discrimination due to factors such as age, gender, sexual orientation, religion, and disability. Staff completed equality and diversity training, which helped develop their understanding around inclusion and celebrating people’s individuality.

Staff feedback was positive. They felt supported and listened to by the registered manager.

The registered manager had effective procedures in place for monitoring the quality of the service. The registered manager carried out a range of audits such as care plans, risk assessments and medicine audits. Policies and procedures were regularly reviewed and updated. The provider was aware of the regulatory requirements about making referrals where required to the local authority and CQC. Accidents, incidents and near misses were recorded and reviewed to see if any lessons could be learnt. Staff attended regular team meetings and supervisions were used as an opportunity to further develop staff skills.

Relatives told us they were involved in developing people's care plans and they felt the registered manager worked with healthcare professionals when required. We saw examples of the registered manager working with healthcare professionals for specialist medical equipment when people's needs changed.

We did not receive any feedback from partners.

The registered manager was in the process of developing some partnership working with other professionals.

The registered manager was committed to creating an environment where quality, innovation and creativity was very much at the core of people's care plan. Staff were encouraged to be creative and innovative in how they supported people. For example, to look for things people can aspire to do, rather than focusing on what they cannot do.

The provider used team meetings and spot checks as an opportunity to learn and improve the service offered.