South Collingham Hall

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

Governance systems in place required further development to ensure the quality and safety of the service was monitored effectively. The management team had oversight of the service, however systems in place required further work to ensure risks and areas for improvement were highlighted and any action taken in a timely manner. There were missed opportunities to ensure staff were included in the running of the service. There was an open culture and staff felt well supported in their roles.

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.

The management team and staff displayed a committed attitude to people. Staff told us that South Collingham Hall was a nice place to work. A staff member we spoke with said, “There is a good team spirit.” A manager explained of their commitment to the service and recognised the importance of improving the service provided. Staff and the manager told us there was an open and transparent culture. Staff were relaxed in the company of the management team.

Processes in place meant there was an open culture. The provider had taken action where needed following concerns raised by the staff team in regard to the management of the service. Where staff did not work in line with the culture and policies of South Collingham Hall the provider took timely action to ensure the culture remained open. Whilst there was a registered manager in place they had recently left the service, and a new manager had been appointed. The manager was present at the home and knew people well. The provider visited the service weekly and knew people and staff well.

Staff knew people well. Staff told us they felt supported by the management team and told us they were approachable. A staff member we spoke with told us they were encouraged to further develop their skills in order to complete their jobs roles effectively. The manager was new to the service and told us they had been well supported by the provider and a registered manager from one of the providers other services. The management team discussed the recent changes to the management of the service and recognised the impact this had on staff. They made changes were needed and reacted to staff’s feedback.

The manager was experienced and was being supported by both a registered manager from another service and the provider to ensure the service was well led. Processes in place needed further development to ensure the quality of the service was monitored and maintained. The manager recognised there was work to do around the auditing process and discussed plans in order to improve the governance arrangements at the South Collingham Hall. The manager had increased their checks on things such as medicines and had recently changed processes. However, other audits such as documentation audits were not always effective in highlighting areas from improvement.

There was an open culture and staff were supported to speak up. Staff told us the manager was approachable and that if they needed to raise concerns, their concerns would be acted on. The provider gave us an example where staff had approached them with concerns, and the action they had taken to ensure the quality and safety of the service was maintained. The provider’s representative visited the service regularly to allow staff to speak with them if needed. Staff were aware of how to raise concerns both internally and externally.

Processes in place needed strengthening to ensure any concerns were recorded and acted upon in a timely manner. The manager was new to post and recognised there had been missed opportunities for staff to raise concerns or share ideas as staff supervisions had not been completed regularly. Meetings for staff, relatives and people did not always take place regularly. This meant there were missed opportunities for people and staff to speak up. The manager recognised this and told us they planned to increase meetings to ensure people and staff were supported to share their ideas and raise concerns if needed.

Staff told us they enjoyed working at South Collingham Hall. Staff told us there had been changes within the management of the service but felt this was positive for the service. A staff member we spoke with said, “We are a good team, and I feel well supported to develop.” The management team displayed a positive attitude and told us they were determined to improve the quality and safety of care provided at South Collingham Hall.

Processes in place were inconsistent. For example, staff meetings and supervisions needed increasing to ensure staff were fully involved in the running of the service. Regular supervisions and meetings provided the opportunity for all staff a space in order to share ideas and raise concerns. An inconsistent approach meant there was a risk not all staff’s voices would be heard. Staff were encouraged and supported to develop their skills by enrolling on courses to develop their role. An equality and diversity policy was in place to support staff.

Staff were clear about their roles and responsibilities. Staff told us there had been a number of changes recently but felt this was positive for South Collingham Hall. Staff felt supported by the manager and the provider and told us they would act on any concerns. The manager and the provider were aware of their regulatory requirements and responsibility under the duty of candour. Duty of candour is a professional responsibility to be honest with people when things go wrong. The manager and provider were open and honest throughout the assessment process. They displayed a positive attitude to the assessment process and was responsive to feedback. We received further information from the manager following our assessment detailing what action they had taken following our feedback.

Governance systems in place needed further development to ensure they were effective. Audits in place needed further detail to ensure action was taken. For example, an audit relating to medicines was identical month to month. Whilst the manager had identified issues, this was documented effectively to ensure progress could be monitored effectively. We discussed the governance arrangements in place and the management team acknowledged further work was needed to ensure these were effective in monitoring the quality of the service. The manager planned to develop the audits further to drive service improvement.

People told us they were supported to attend healthcare appointments. We received positive feedback from all people and their relatives we spoke with regarding gaining access to healthcare services. However, people and their relatives fed back they would like to undertake more activities of their choosing such as spending more time in the community. There was no structured programme in place to support people to visit the community. This meant people did not always have the opportunity to spend time doing things they enjoyed. People told us they were supported to maintain contact with those important to them and relatives told us they visited South Collingham Hall as and when they wanted.

Staff and managers gave us examples of working with other healthcare professionals to improve people’s outcomes. Staff discussed working with the community nursing team to ensure a person living with a complex health condition was supported to maintain a healthy lifestyle in order to improve their health. Staff recognised the lack of social opportunities and how this may impact people. The management team told us they were trying to recruit an activities coordinator however, there were no plans in place of how they would increase activities whilst recruiting to this role.

Professional’s we spoke with spoke positively about South Collingham Hall. Staff were praised for their approach and communicated well to ensure people received timely care.

Processes in place meant referrals were made to other professionals when needed. When professionals provided advice and guidance this was implemented into care records. For example, where people had attended hospital appointments information relating to appointments was clearly recorded. This meant staff had correct information to ensure people received the right care and support. However, there were limited processes in place to ensure people participated in a wide range of activities. This meant people were not always provided with opportunities to undertake hobbies and interests of their choosing.

The management team told us they acted upon feedback from external audits such as the local authority. The provider told us of action they had taken to improve the infection prevention and control arrangements at the service following an external audit from the local health team. The manager told us they were working with the pharmacy team to improve the medicine arrangements at South Collingham Hall. This was to improve the quality and safety of medicines management.

Processes in place needed strengthening in order to promote quality improvement. Whilst audits and recording of incidents were in place these were not always detailed. This meant there were missed opportunities for lessons to be learnt. Best practice guidance was shared and followed in the home. For example, where people were at risk of malnutrition best practice guidance was implemented to ensure timely intervention.