Sabin Care

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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

This key question has been rated requires improvement. We reviewed 7 quality statements for this key question. The registered manager did not have adequate oversight of the service. Staff reported the manager was supportive, and they felt engaged with the service however the processes in place did not support this. The quality assurance processes in place were not effective. We identified a breach of the legal regulations.

This service scored 57 (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 us the registered manager shared the direction of the service and promoted a positive culture however this was not documented. Staff confirmed they attended staff meetings where information was shared however meeting minutes lacked detail and did not record staff involvement. The registered manager did not record supervisions or appraisals.

The provider did not have robust systems and processes in place to share and drive the culture in the service. There was no evidence of staff engagement in staff meetings. The registered manager did not record supervisions or appraisals.

Staff gave positive feedback about the registered manager. Comments included “They [registered manager] are professional and are doing their best. I really like their principles” and “They [the registered manager] are very good and they listen to staff. Very accountable, professional and supportive.”

Although the registered manager demonstrated they were open and compassionate throughout the assessment process, and this was corroborated by staff. We found the registered manager lacked oversight of the service. The registered manager did not provide evidence to demonstrate how the service was well led. The lack of systems to monitor the quality of the service did not allow for lessons to be learnt. There was limited evidence actions were taken to drive improvements in the service. For example, actions following audits were vague and unclear. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff were able to demonstrate their knowledge and understanding of their responsibilities relating to reporting concerns. Staff said they felt confident that where issues were raised, the registered manager would support them through it.

The registered manager told us they asked for staff feedback however this was not recorded. The provider had policies and systems in place, which aimed to foster a positive culture where people could raise complaints.

Staff felt the manager was fair and treated everyone with respect. The registered manager told us staff completed equality, diversity and human rights training and they employed a diverse workforce.

The provider had a fair recruitment process, and we saw staff files with the required level of compliance. Training, policy and procedures were in place to support equality, diversity and inclusion.

Staff told us the service was well led, and the registered manager was a supportive leader. However, the systems and processes in place for monitoring needed improvements for example, the recording of formal staff engagement.

The provider did not have consistently effective governance systems in the service to drive improvement. Whilst there was evidence of monitoring systems in the service, these were not always effective in identifying shortfalls and monitoring when actions were taken. For example, although audits were completed, identified issues were not clearly documented and there was not always evidence of actions taken. This meant the registered manager was unable to demonstrate their oversight and analysis of any potential patterns or trends. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Feedback from people and their family was positive. Although we were unable to talk to people who used the service and their relatives, feedback forms evidenced no concerns were raised and overall people were happy with their care. The registered manager worked in partnership with other professionals to ensure people’s health and social care needs were met.

Feedback from partners and stakeholders was positive and no concerns or comments were raised.

Systems were in place for staff to inform the registered manager if they had concerns about people’s health and well-being. Managers were responsive and escalated any concerns about people to relevant health care professionals, this was evidenced in care records.

Staff told us learning was shared through a staff WhatsApp group and team meetings. However, the recording of team meetings was limited. Team meeting minutes were available for staff to view who had not been able to attend.

The service did not focus on continuous learning, innovation and improvement. The lack of governance meant areas for learning and development were not identified so improvements could be made. For example, the improvement plan lacked details, was vague and not dated. This placed people at risk of harm. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.