Scholars Mews Care Home

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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

There was an improved culture within the home. Senior representatives from the provider group, including the quality assurance team, carried out regular visits to check the quality of care provided to people. Systems and processes had improved. Records showed regular audits and checks took place which assessed and improved the quality of care provided. However, the quality assurance process had not identified some of the shortfalls identified during our assessment such as a lack of information being shared when people moved between services, consent and dignity issues related to the taking of clinical photography. Following our feedback, the provider responded to make the required improvements. Staff were confident to speak up and report any concerns senior management. The provider’s policies supported workforce equality, diversity and inclusion. There was no registered manager in place at the time of our assessment, but the Regional Director who was in day to day management of the home had applied to become registered with us, CQC.

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 described an improved culture within the home and increased visibility of senior staff and leaders. One staff member reflected on the last inspection report and told us, “We had lots of meetings about the issues, and they talked about all the problems. We have had lots of training; some face to face and some online.” Another staff member told us, “Staff should feel proud. It's now a happy, laughing place and the residents are our family. There's a different atmosphere now.” Staff told us there was now a culture at the home which encouraged them to escalate any concerns they have. For example, 1 staff member explained they had identified a training need in the way a colleague was using equipment to support people. This staff member explained the senior member of staff tactfully took action to address this. This helped to ensure action was taken without creating animosity within the staff team. The regional director told us, “Our values are new. Leaflets have come in and have been put around the home and we will be focussing on a value each month. We have merged two companies together following an acquisition and we have just merged the two values / vision’s together as, one family. Changed following acquisition. Staff were involved in choosing the 5 values. We wanted the acquisition to feel welcome.”

Systems and processes were in place which ensured staff understood the provider’s vision. Posters were present around the home of the providers new values since they changed after the acquisition of new homes. These values were also covered in the induction. Records showed staff meetings were held regularly.

Staff told us about the recent improvements to the service and told us the home was now well led. One staff member said, “There have been good improvements. People’s records are now up to date, staffing levels and training are better. [Night manager and senior staff] are approachable, and you can talk to them and the deputy manager and the regional director We see regional director at nights. Another staff member said, “Support from the interim manager is good. Nothing is too much trouble for them.” The staff member also told us support from the peers was excellent. The Operations Director told us since of last inspection, changes had been made within the provider’s senior leadership team to ensure the home was supported by high quality leaders who were skilled in making the required improvements. They explained, “We commissioned an internal investigation and as part of that process we identified a change in leadership was needed. This reviewed all levels from general manager level through to the director of quality.” The Regional Director told us, “I have been part of the journey and am very committed to this home. I have applied to be registered and I am not planning on taking a step back. They all want to succeed now.” One staff member told us the provider’s senior leadership team were more visible in the home and said, “When they come, they say hello and ask if everything is okay." Staff well-being was supported by an application on their phones where they could access a variety of different support functions which were appreciated by staff.

There was an effective system in place to support the leadership team. Senior staff were supported through regular supervision and appraisal's where they discussed their role and performance. There was a programme in place which recognised and rewarded staff who had gone above and beyond in their role. Senior staff were either working through or had achieved health and social care qualifications. Leaders had access to latest best practice guidance.

Staff told us they felt confident to speak up and report any concerns or issues about the practice of other members of staff. One staff member told us they would not hesitate to whistle blow because, “The residents are the reason we are here. They are our priority, not the carer. The way we treat them matters." Another staff member told us, “I know my responsibilities and I know I must speak up if I see poor practice. I would be listened to if I reported things. I know [night manager] would escalate.” At our last inspection there was a poor culture where staff did not always feel they could speak up. When staff did speak up, appropriate action was not always taken. The Regional Director told us making improvements in this area had been the primary focus and told us, “We have done a lot of work in this area to create a culture where people, staff and relatives can talk to us with confidence. We do regular 1to1 staff supervisions and staff meetings. Staff all have access to my mobile and know I have an open door. I am very visible on the floor. I am out there speaking to relatives and residents. Staff now raise things with me.”

The providers systems and processes supported staff to speak up. We saw a variety of records such as team meetings, handover documents, supervision matrix, questionnaires and surveys where staff had the opportunity to speak up about concerns they may have. Staff had received a themed safeguarding supervision, competency check and training in safeguarding to ensure they understood their responsibility to speak up on behalf of people. Records show when concerns were raised, these were investigated and escalated internally and externally to the local authority where required. The provider's policy supported this practice.

The deputy manager told us adjustments were made to support people’s religious belief's. They explained how the small library had been turned it into a prayer room during Ramadan and additional breaks were allocated which enabled staff to pray. One staff member told us, “Here we are all from different cultures, but we are treated equally by [Regional Director].

Records showed staff received training in equality and diversity which encouraged staff to challenge discrimination. The provider’s policies supported workforce equality, diversity and inclusion. Where staff issues arose, thee were addressed by the Regional Director through investigation meetings to ensure employees worked in a safe space free from harassment or bullying.

The Regional Director explained how they had worked hard since our last inspection to improve people’s experiences through a more robust quality assurance process. They had increased the frequency and quality of internal audits, as well as investing in staff, closer monitoring of staff practice and listening to people and families’ feedback. The Regional Director felt the home was in a much better position and this was down to everyone’s commitment to ensure the service provided was what people expected. The deputy manager told us how staff day to day practices was checked through daily walk rounds and competency checks for areas such as moving and handling, how staff interacted with people and completion of care records. This helped to provide assurance about the quality of care provided. The Operations Director told us how improvements had been made to the providers oversight of quality in the home and told us, “The quality role was very different before. Our quality team are now more visible in the homes." They also explained how a variety of support calls were in place where senior leaders would continually be checking that the home is moving forward.

Overall, records showed the provider had effective systems and processes to assess the quality of care provided. Records showed audits and checks regularly took place to assess important areas such as medicines, infection control, health and safety, care plans and the environment. Any actions identified in audits and checks were transferred into the home’s 'sustainability action plan' which acted as a central action plan for overall improvements which was then discussed with senior leaders regularly. The provider completed an analysis of accidents and incidents, safeguarding concerns and complaints. Records showed senior representatives from the provider group, including the quality assurance team, carried out regular visits to the home. However, the quality assurance process had not identified the shortfalls in a lack of information being shared when people moved between services, consent and dignity issues related to the taking of clinical photographs. Following our feedback, the provider responded to make the required improvements.

People and relative's reflected on the journey the home had been through and told us things had improved. One relative said, “It has improved from before. We get phone calls and messages when needed, and I can speak to staff anytime.” Some relatives raised concerns that current manager would leave if the CQC rating improved as they were at the home as a temporary measure.

Following our last inspection, we received feedback that relatives did not feel the provider had been transparent about the failings identified in our last report and told us there was limited communication. We discussed this with the Operations Director and the Regional Director who told us communications between them, and relatives had improved. The Operations Director told us, “Senior leaders have responded to the concerns raised by relatives, and we have held numerous meetings with them. During these meetings relatives do speak up and we are committed to working with them and to ensure clear lines of communication.” The Regional Manager told us how relationships had been developed with healthcare professionals and the local authority. The Regional director told us how they worked with another care provider to ensure a home the person and their family chose was suited to their needs. They explained how they worked closely with a social worker, a GP and the new care provider to ensure the person's move to another home went smoothly.

All healthcare professionals we spoke with commented on the improvements at the home in the past 6 months particularly since the Regional Director had taken over managerial responsibility for the home. One healthcare professional commented, "I would say [Regional Director] is very open and honest now.” One healthcare professional commented, “I feel that the management team have made many steps to improve quality of care within the home. The deputy manager is very efficient and organised and has taken on board making many changes and has updated and reviewed their policies to improve on things.”

Records showed the provider had worked in partnership with the local authority and their 'service improvement plan' had been completed. Learning from the last inspection had been shared across the provider group to improve outcomes for people. Records showed the home had started to work as an active part of their community. People within the home had recently supported a local food bank.

The Operations Director told us since the last inspection they had been intensely working through an action plan. This action plan was central to logging all of the actions and completed actioned which was owned by all senior leaders. The Operations Director explained lessons and been learnt from the last inspection. One of those lessons was in the absence of a Registered Manager, the Regional Support Manager would automatically go in and manage the home. This had not happened previously due to senior leadership changes. New processes had been implemented to prevent this happening again. It was also identified some of the failings had occurred due to poor staff competency. The Regional Director told us changes had now been from recruitment, training and staff supervision. At our last inspection falls management required improvement. The Regional Director showed us updated systems and processes to better record people’s falls risks which the provider was introducing across all of the provider’s homes. The Regional Director explained these risk assessments better recorded more specific and individual risks, so staff had more information to support people’s safety. The Regional Director told us these new systems had been designed through learning from their own internal quality assurance teams. The Regional Director told us there were areas for improvement which they continued to monitor and improve. They remained confident their improvements would be sustained and had started to become embedded into everyday practice to improve the quality-of-care people received.

Records supported a positive learning culture. Where audits and checks had taken place, senior leaders ensured any actions and learning were continually reviewed via their electronic quality monitoring system. Where significant incidents had occurred, records showed these were reviewed to identify where any lessons could be learnt. Records showed that learning from our previous inspection had been shared across the provider group. For example, a 'serious escalation process' was introduced where significant incidents were escalated to the senior leadership team. This created a chronological electronic trail of all interventions following the incident to ensure appropriate actions had been taken to avoid the incident happening again. A ‘Lessons Learnt’ report was also completed where significant concerns had been raised. We saw an example of where a relative had raised a concern. Duty of candour had been followed and the actions identified had been completed.