Southborough Care Home

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 – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation governance at the service. Medicine audits were not identifying concerns found in relation to safe practice

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager was committed to providing a good service for people. They knew people who lived at the service and staff well. However, the registered manager and staff had not identified their oversight processes were not picking up the concerns we identified. Whilst the registered manager was very responsive in taking action, more work was needed to develop strategies with staff to ensure they and senior staff identified the concerns independently. Staff were mainly positive about working at the service. A staff member told us, “I would recommend this as a good place to work.” Another staff member said, “Teamwork is great here; we all help each other as much as we can.” Opportunities for staff such as supervision meetings did not always demonstrate involvement from staff. This meant whilst staff told us they felt supported there was minimal evidence to demonstrate their involvement in the direction and culture at the service.

The registered manager was visible at the service and staff, relatives and people were positive about the management of the service. They told us, “Every day I am motivated with what we are trying to achieve, I want a consistent staff group. We try to avoid using agency staff.” However, more work was needed by leaders to strengthen the oversight at the service and look at the systems and processes they had in relation to governance and auditing to find out why they were not always working. Staff were positive about the registered manager and senior staff at the service. A staff member told us, “The manager is good to have around and available.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were confident they could raise concerns and they would be listened to. A staff member said, “[Registered manager] does listen to us we tell her and she gets it straight away.” A whistle blowing policy was in place and staff knew where to access policies.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. However, the provider needed to improve their processes around staff engagement as there was minimal evidence seen in supervision records of staff inclusion, ideas or feedback about their work. Staff we spoke with were happy with the morale and the service and told us teamwork was good. A staff member said, “Staff are working well as team, it is good teamwork here.” Staff had completed equality and diversity training.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Robust systems were not in place to monitor and review all areas of the service, failing to identify the issues found during this assessment process. Medicines audits were not effective in identifying gaps on the medicine administration records. A medicine being administered and not signed for, there was no effective process to reconcile medicines to ensure people were receiving their medicines as required. We identified some risks to the environment such as inappropriate methods used to secure wardrobes to walls, lack of a grab bag or all versions of PEEPS updated and reviewed. Whilst the registered manager acted straight away and fixed the environmental concerns their own internal audits had not picked up these issues.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. We received mixed feedback from professionals in relation to collaborative working with 1 reporting staff were resistant to their suggestions as recorded in the effective section, however another professional said, “There the best in this patch, the registered manager is very responsive and communicates well, it is very low here for pressure ulcers and wound care. They recognise deterioration and contact us for support. Staff are very friendly.”

The provider looked for additional learning when needed, however processes did not always demonstrate staff were involved in improving and developing the service. One-to-one supervision records did not capture staff feedback, suggestions or ideas. Staff meetings were held and these were better at demonstrating the involvement of staff. The registered manager told us they actively engaged with the local authority to access any new training and develop staff skills. A staff member told us, “I have recently completed additional learning disabilities training.” People and relatives confirmed they were asked for feedback and the previous surveys looked at contained positive responses.