Treasure Vince

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

At the last inspection we identified a breach of Regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider did not operate effective systems and processes to assess and monitor the quality and safety of the service. At this assessment we can see the provider has made improvements through assessing risk and implementing audits however these are not yet embedded. Enough improvement had been made at this assessment and the provider is no longer in breach of regulation 17. However the registered manager should continue to embed safe systems to monitor and improve the quality and safety of the service.

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.

One staff member said, “I’ve undergone extensive training and continuous learning to excel in my job role. I’m confident in my abilities to perform effectively and adapt to any challenges that come my way.”

The registered manager said, “We have monthly meetings. Everyone shares their views how we can move forward. We discuss lessons learnt and I observe their work.”

The registered manager was responsible for delivering care alongside the staff they employed. Staff told us they registered manager was aware of their responsibilities with regards to the people they supported.

The provider had sought support from a consultant and was in the process of changing to new electronic systems. The provider felt this would enable them to have a clearer oversight of the service and for information to be more readily available to them in order to fully meet the needs of the people they supported.

Staff told us they felt listened to and that the registered manager was approachable and supportive. One staff member said, “We have regular supervision and team meetings to ensure effective communication and collaboration among team members.”

The registered manager said, “We have a complaints policy and a whistleblowing policy, all staff are aware of the policies and procedures. We have regular supervisions, where we discuss complaints and how to report safeguarding’s and I do surveys with clients to get their feedback on the care.”

Staff told us communication within the organisation was effective and that the registered manager was always available and responded quickly.

The registered manager led by example and was in the process of implementing a range of policies that promoted equality, diversity and inclusion and person-centred care. The registered manager said, “We make changes to our rota to accommodate religious events that are important to our staff. We communicate the changes with the services users and their families when needed. We have a diverse staff team.”

The registered manager said, “We are registered with an agency who can provide emergency cover if needed. There is a senior member of staff who can also help cover in the absence of registered manager.”

The registered manager shared their audits, care plans, risk assessments and team meeting notes with us. We can see there has been improvement since the last assessment when these systems were not in place. The systems and processes are not yet fully implemented and therefore are not sustained, the registered manager told us they are working to move forward and make improvements.

Relatives told us they felt the service would liaise with relevant health and social care services when needed. Comments included, “They would certainly organise things if we needed any further support."

The provider valued the support received from health and social care professionals over the past year.

The registered manager said, “I made a referral for one person who needed bedrails. I worked with the occupational therapist to achieve this for the person to reduce risk to them. We also work in partnership with families, if the person lives with their family we might ask the family to refer to a GP.”

The registered manager had consulted a professional to help them with implementing recording and oversight systems. This includes audits for quality assurance purposes. However, at the time of our assessment the registered manager had not consistently completed their audits. The registered managers oversight systems required further embedding to ensure the safety and welfare of the people they support.

The registered manager had in place a lessons learnt file which they had not yet implemented. Discussions around the last inspection and the concerns found had not been discussed with the newly recruited staff. We saw staff meeting minutes which had no mention of lessons learnt however the registered manager told us lessons learnt are shared with staff.