- Care home
Derby Heights Care Home
Report from 25 March 2024 assessment
Contents
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
Well-led
Well Led- This key question has been rated Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. The provider encouraged learning and innovation and promoted an open and fair culture.
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 told us how they gathered feedback from people using the service, staff, relatives, and stakeholders to use this feedback to drive improvements where it was needed. The provider had initiatives in place to ensure staff were aware of the company’s values and how they could embed these into their day-to-day work.
The registered manager had a clear vision of the culture they wanted to promote as well as any plans for improvements. Input was sought from people and staff in service delivery. Since the registered manager had been in post, they had developed a home action plan supporting their vision.
Capable, compassionate and inclusive leaders
Staff consistently spoke positively about the registered manager and the changes they had made since they had been in post. The registered manager and provider were passionate about delivering quality care to meet people’s needs.
People gave positive feedback about the registered manager who they found to be approachable and welcomed the changes they were making. One person said, “The new manager is very friendly and makes themself known to everyone.” A relative told us “The change of manager has increased staff morale and enthusiasm. It’s back to being 5 stars.”
Freedom to speak up
Staff told us they felt the management team were approachable and able to raise any concerns they had. The registered manager and provider also told us about the systems they had in place to ensure staff could speak up anonymously about any concerns if staff did not wish to share this with the management team. Staff understood how to report concerns to external agencies if required.
The provider had a whistle blowing policy, which was reviewed ensuring the information was up to date. The registered manager held meetings with people, relatives and staff promoting an open-door approach to raise issues.
Workforce equality, diversity and inclusion
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.
Governance, management and sustainability
The registered manager and provider told us about the robust systems and processes they had in place to ensure all aspects of the service were regularly audited and how action plans were in place to drive any improvements they identified.
There were systems in place to monitor the quality of the service, which included audits and regular checks completed by the management team. A home action plan had been put in place by the registered manager which identified some improvements and action was underway to addresses these. Manager daily walk rounds were completed carrying observations of the environment, speaking with people, and checking care records.
Partnerships and communities
The staff team worked with other professionals to help ensure people's changing needs were monitored and met. One person told us, ‘The dentist and optician come in and you can request to see them.’
The registered manager and provider told us how they worked closely with external professionals to meet people’s needs. The registered manager also told us about their links in the local community and how different organisations and entertainment frequently visited the service.
Feedback from professionals was complimentary, they were positive about the quality of care and support provided. A professional who worked with the home stated staff were visible and caring. They felt staff were aware of people’s needs, providing them with valuable information enabling them to make clinical decisions about people’s care.
Effective partnership working was in place to support people to access appropriate healthcare. Records confirmed people regularly saw other professionals when needed including GP’s and District Nurses. Weekly ward rounds took place where a health care professional visited the home, reviewing people who may have had acute or ongoing health issues. The registered manager told us there was a professional hub within Derby Heights Care Home. Front line professionals were able to use the designated workspace within the home to complete information and paperwork, which was risk assessed.
Learning, improvement and innovation
The registered manager was new in post; however, they told us they identified and created an action plan on key improvements such as changes to the environment to support people living with dementia.
The provider had systems and processes in place for continuous learning, innovation, and improvements to the service. The registered manager encouraged learning. They felt this aimed to enhance the staff team, making them feel valued and supported in their roles with appropriate training. Systems were in place to learn from incidents, to prevent reoccurrence of incidents. Feedback was also received via surveys which provided people with the opportunity to share ideas and feedback to drive improvements as required. Results from the recent surveys showed feedback had been listened to and used to make improvements to the service.