Miramar 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

The key question of Well Led was rated Good at our last inspection and continues to be rated Good following this assessment. However, the management team had not always followed the provider’s processes to make sure potential risks to people were managed. The provider had recently identified these shortfalls including not incorporating learning from incidents into people’s care plans. The provider had put action plans in place and they were completing regular checks and audits on the service.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

The registered manager was working her notice and a new manager had been recruited. The new manager worked for the provider and was aware of their policies and processes. Staff, people, and their relatives had been informed of the change in leadership. The new manager had visited the service before our assessment and staff had the opportunity to meet them. Staff told us they felt supported in their role. A staff member told us the current registered manager encouraged them. They also told us this had boosted their confidence in their role and helped them to develop. Other staff told us the registered manager and deputy were approachable and took time to listen to and address any concerns they had. The registered manager told us they visited the service unannounced once a month each month to check the quality of the service being provided. They told us they had not identified any risks relating to people’s care. The registered manager described to us the oversight process the provider had in operation. This included a safety team who analysed information recorded on electronic systems to look for any pattern and trends at the service. The registered manager told us they submitted a governance report detailing what had happened at the service to the provider each month and any action they had taken to improve the quality and safety of the service. The registered manager told us the provider had acted on recommendations from Kent Fire & Rescue Service to improve fire safety at the service.

There were systems in place to monitor the quality of the service including provider led audits and monthly checks completed by the management team. The provider audits had identified some shortfalls in practice. For example, the care plan audits showed that care plans were not always updated when a risk had been identified. An action plan had been put in place and some improvements had been identified, however, following the next audit further improvements were still needed. The audits completed had not identified the shortfalls in the guidance for staff around potential risks to people's health and welfare, including managing people's distress or anxiety, which we identified at this assessment. The management team had completed checks and audits on all aspects of the service and had put action plans in place to rectify shortfalls such as areas of the service not being cleaned at night.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.