The Reeds

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

Systems were in place to monitor the quality of the services provided for people and to support staff to raise concerns. However, the provider failed to ensure some processes to monitor restrictions were in place. The provider acknowledged where actions taken to resolve an issue had not been effective and assured us this would be addressed.

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.

Some staff felt positive about working for the organisation. A member of staff told us, “I think highly about the organisation. [The provider has] Been supportive and have done to so many colleagues across the organisation... so that we all pull in the same direction.”

The provider had a clear vision of the type of service they wanted to provide. This included ensuring people lived their life to its fullest. They did this by using data to inform improvements in the support provided for people and supporting staff to develop their skills and knowledge.

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.

The provider had a process known as ‘Raise It’. Records indicated that some staff were happy to use this process. Some staff we spoke with were happy to raise concerns with the provider and had several different options on how to report any concerns they had. One staff member told us any issues they had raised had been addressed and resolved quickly. However, multiple anonymous concerns were raised with us prior to this assessment about staff’s reluctance to share their concerns with the provider. The concerns raised indicated some staff lacked confidence in the provider’s response. We spoke to the provider about this and they told us how they would address the issue. For example, a director of the provider organisation had taken steps to reassure staff via their social media platform that they were open to concerns being raised with them and committed to taking appropriate actions to resolve any issues.

The provider had a ‘Whistle blowing, Speak up, Speak Out’ policy in place. This policy outlines where and how people could raise concerns under Whistle blowing legislation. Guidance was available within policies to support staff to speak out if needed. Policies contained information on how to contact external agencies. This information was also available on posters in the office at the service. However, whilst there were processes in place for staff to raise concerns internally, some staff were reluctant to use them and raised concerns directly to CQC as they lacked trust in leadership to take their concerns seriously.

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 told us the provider’s governance and assurance systems helped to support them in their management role. For example, they spoke about the effectiveness of central planning of staff rotas, the oversight of incident recording and care review processes. A member of staff told us how the centralised monitoring team for night-time support helped them to improve monitoring and support of people’s needs throughout the night.

The provider’s quality monitoring processes were embedded into the service by the provider, who used teams of staff working centrally to undertake quality monitoring audits in all their services. This ensured there was constant oversight of the service. To support this, managers on site undertook walk rounds and carried out weekly audits of the environment. They then provided feedback to a central team so the environment was maintained. Twice weekly governance meetings were held with groups of managers to review information gathered around people’s behaviour patterns. The information was analysed to look at what strategies had been used by staff and how effective they were in reducing people’s anxieties. The provider told us how their governance processes had identified the wording used in care records was not always as dignified as it could be. They explained how they had implemented support from more experienced staff to review and suggest more dignified phrasing. The registered manager and staff had regular meetings to discuss how the service was running, how people’s needs were being met and any improvements that needed to be made. However, as noted in an earlier section of this report, we saw a member of staff had failed to keep their alarm and radio with them when supporting a person outside. Records showed that this situation had occurred on multiple previous occasions. This meant that although the provider’s systems had identified the issue, actions taken to address this issue had not been effective. We also identified the lack of monitoring and review systems for the restrictions on people’s free movement around their home.

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.