Pogles Wood

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 requires improvement. At this assessment, the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. In part, we assessed Pogles Wood due to concerns which were raised following an application to add an additional person to the service. Discussions with the registered manager did not always indicate good governance or an awareness of good practice guidance and requirements around learning disability and autism services. During our assessment we found service provision to be in line with right support, right care right culture, however the registered manager had not previously been familiar with the guidance. We found information in records such as a pain risk assessment that needed to be separated into a PRN protocol. This meant some areas we had concerns about prior to assessment had been completed however, they were not necessarily recorded where they should be. Staff were happy with the management of the service, and the owners displayed its values in their leadership. There was an open and honest culture and there was a whistleblowing policy. Neither staff nor the registered manager had any doubts that poor practice would not be immediately addressed. The provider had ensured positive working relationships had been formed with healthcare professionals involved in the care of the person. This ensured a seamless service could be delivered to them.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider aimed to deliver a bespoke care package to the person they supported ensuring they were central to provision, and which focussed on their capabilities not their disabilities. This had been achieved, and in speaking with staff members we found there was a strong commitment to the person they supported with the focus being on enabling their participation in a fulfilling life. Staff had completed training in equality, mental capacity and dignity in care. They were constantly looking for ways to include the person in their community and in different activities to enhance their life experience. The culture in the service was extremely positive. It had a feel of being family orientated with aspects of professional care as needed. The service was adapted to suit the persons needs and additional improvements such as adding a paved area in a shady area of the garden this year enabled them to enjoy being outside with lower risk of seizures caused by being too hot.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, however they lead with integrity, openness and honesty. The registered manager was also the nominated individual and one of the owners who, with the co-owner had previously cared for the person when they were in a cared for children placement. Both owners took a leadership role in the service and had extensive knowledge of the person they shared with staff. The registered manager had almost completed their level 5 diploma, and the team leader their level 3 diploma when the training provider ceased trading. The registered manager is looking to complete the level 5 shortly and the team manager is now working on their level 4 diploma. There was clearly a conflict in how the service had been managed, it is a family home but also needed to be treated as a care home. However, this meant there was a commitment to the person throughout the team as a result of the open and honest approach of leaders. The registered manager was not completely clear as to how the Regulations applied to Pogles Wood. This was understandable as they provided only 1 care bed and to a person they had known for many years. However, have provided evidence and had met the required standards in most areas and since our assessment have met all shortfalls noted.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a very small staff team, and those we spoke with told us they were confident they could raise anything with leaders. They also had a whistleblowing policy and staff were aware they could approach outside agencies if they had concerns about any aspect of the service. The daily meetings meant the team and leaders had regular discussions and the registered manager and co-owner worked alongside care staff in supporting the person. This gave an opportunity for open discussions and both the staff, and the owners were transparent and shared any concerns. We discussed issuing quality assurance questionnaires however with just 3 staff, all of whom at the time of assessment were confident in speaking up, not having these had little impact on service provision.

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. Staff completed training in equality. Staff were also confident diversity was valued. One staff member told us, “A good example of inclusiveness is me; I am 70 years old!” We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. During our observation we saw the person remained the absolute focus of staff who included them in various activities with sensory items. They had also taken the person out to the shops that morning for items needed for their care, they made sure to visit the persons more favoured stores that provided them with intense sensory experiences while out. They focussed constantly on including the person in fulfilling activities and their community.

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. The registered manager had set up basic auditing tick sheets however lacked more in-depth analytical audits that could improve oversight of the service. However, there was minimal negative impact as they provided to 1 person only and met daily to update themselves. The provider also did not utilise widely available resources including good practice examples relevant to their service. We signposted them to resources about, for example, MCA, risk assessments, and medicines administration. Following the assessment, the provider shared evidence with us of actions they had taken. This showed they had already utilised these resources to improve staff supervision records and their understanding of the requirements of the MCA in their setting.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider had formed positive working relationships with relevant healthcare professionals. This ensured the person had healthcare that was linked and that professionals were all informed of relevant information. They had also enabled the person to attend local day care provisions such as a dancing group and a specialist day centre. On a day-to-day basis, particularly when we visited, the person had daily outings to access the community for walks and visits to local places of interest such as the beach and the quay. Relationships had also been formed with other small care providers locally and social meet ups happened that benefitted the person and others.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The provider demonstrated their commitment to learning and development by the actions they took at the time of and following our assessment. The provider did not consider their service to be a standard care home, they said several times and in their Statement of Purpose that the service is “a uniquely bespoke service for each [person] which is created and implemented solely on their needs and requirements.” In order to achieve this, observations and interactions with the person were continually analysed and learning taken from these to shape future services that provided bespoke, individual care to people. Learning was also taken from accidents and incidents however, there was a single recorded incident, so this had a minimal influence on service provision. The registered manager and team leader were completing diploma level training, and this was available to all staff. All staff had completed an induction, and the Care Certificate and training was completed as required. In addition healthcare professionals such as the PEG feeding specialist nurse led specific training around the person and their requirements that was completed by staff. Since our assessment, additional training in MCA had been arranged for staff and the provider has been signposted to good practice sources of information.