- Care home
Lotus Care Marmaduke Street
Report from 26 June 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
We assessed 7 quality statements in the well-led key question. The assessment of these areas indicated areas of good practice and improvements since the last inspection, our rating for the key question has changed to good. The provider had comprehensive governance and assurance systems with clear lines of responsibility and accountability. Governance systems and audits were mostly effective in identifying and addressing areas for improvement. There were some gaps in records and some environmental hazards, however they were immediately acted upon and better oversight of these was implemented. Leaders promoted a culture of continuous learning and improving the quality and safety of the service and ensured learning was shared across the staff team to help mitigate future risk. Leaders had the required skills and knowledge and promoted an open and transparent culture. People and staff felt empowered to speak up and were confident their voices would be heard. The provider worked with other external bodies to share learning and help improve the quality of people’s experiences.
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 they had seen improvements in the direction and culture of the service since the appointment of the current manager. They said moral had improved and described the manager as fair and approachable.
Processes were in place to help staff understood and shared the vision and culture of the home. Policies and procedures were in place to help guide staff in the safe delivery of care and practice. Operating procedures were also in place for staff to follow and referenced good practice and any relevant legislation.
Capable, compassionate and inclusive leaders
Staff described a period of unsettlement due to the high turnover of managers. However, they felt the current manager had brought about positive cultural changes.
Processes were in place to help ensure leaders embodied the culture and values of the service and led staff effectively. Although the service did not have a registered manager at the time of our assessment, governance oversight was in place and an interim manager was in post. The governance team demonstrated they had the experience and capability to help ensure risks were well managed. Leaders were visible and led by example. Leaders demonstrated they were knowledgeable about issues and priorities for improving the quality and safety of the service. Reflective processes, such as staff supervisions and policies helped ensure staff were provided with the appropriate support and development for their role. Leaders helped shape a positive culture which helped to improve the quality of people’s care.
Freedom to speak up
Staff felt able to speak up and share any concerns, ideas and opinions. They felt things had improved recently since the appointment of the interim manager who they said listened and valued their point of view.
Processes were in place to help foster a culture where people felt they could speak up and have their voices heard. A Whistleblowing policy was in place and provided staff with clear guidance on how to raise concerns. The policy also contained contact details for the local safeguarding team and CQC.
Workforce equality, diversity and inclusion
Staff told us they were treated fairly and felt valued and included. Staff provided examples of how managers supported them to work flexibly to suit their needs.
The provider had processes in place which promoted an inclusive and fair culture for employees.
Governance, management and sustainability
Managers understood the providers governance systems and their roles and responsibilities for ensuring they were used effectively to measure the quality and safety of the service.
There were effective systems and processes in place to measure the quality and safety of the service. The manager had overall responsibility for ensuring day to day quality and safety and had the full support of a senior management team made up of different specialisms including Quality and safety and clinical governance. Together the management team developed a service improvement plan setting out areas for improvement, who was responsible for the actions and timescales for completion.
Partnerships and communities
People told us staff worked well with other services. One person told us the dentist attends the home and communication with paramedics was always good if needing to go to a hospital appointment.
Managers and staff understood their responsibilities for working in partnership with others.
Feedback from partners about whether staff understood their duty to work in partnership and shared information to help ensure services worked seamlessly for people, was mixed. One external professional told us, “The management team appear to be open and transparent. We required a response along with supporting documentation. This was provided within the timescale requested.” Whilst another professional commented, “I did not find the management team worked well with getting information that I needed for a safeguarding enquiry, or they listened to feedback. There was a change in management during the enquiry and it was hard to get hold of deputy or stand in manager to help me obtain the information I needed.” We spoke to the management team about this who explained the service had undergone a change in manager and in the interim period, responses had not been as timely was they would have liked. The new manager confirmed that going forward, any requests for information by external stakeholders would be given priority.
Processes were in place to help ensure the service worked in collaboration with partners to help deliver a seamless experience of care for people. Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders and agencies. Staff worked in partnership with key organisations to support care provision, such as with dietitians and GP’s. Staff and managers engaged with partners to share learning with each other that resulted in continuous improvements to the service, for example, monthly clinical meetings and cross service manager meetings. They used these as opportunities to identify new or innovative ideas that could lead to better outcomes for people.
Learning, improvement and innovation
Managers had a clear understanding about their roles for ensuring learning and improvement. They developed improvement plans and shared any learning with all staff.
Although processes were in place to help ensure the provider focused on learning and improvement to help deliver safe and high-quality care to people, recording and analysis was not always as robust as it could be. For example, one person sustained a high number of falls, although these incidents were recorded, it wasn't always evident a full analysis had been carried out to help establish the cause. This meant there were missed opportunities to put in place effective mitigation measures. Managers actioned this immediately by implementing a more robust system for analysing incidents. Processes were in place to learn from safeguarding incidents, with evidence of what action had been taken to learn from incidents and reduce the risk. Governance systems helped to support this. For example, to help mitigate the risk specific to 1 person, the service implemented daily call bell checks and flash meetings. The Medication policy referenced the manager’s role in acting upon medication alerts, which helped to contribute to safe and effective medicine practices.