Blackthorns

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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

We assessed 7 quality statements from this key question. The scores from these areas rated this key question as requiring improvement, which meant the rating of good given in our last inspection (published March 2023) had not been maintained. We found a breach of the legal regulations relating to good governance. This was because the systems in place to assess, monitor and improve the quality and safety of the service were not always effective. This led to the service failing to identify concerns independently through their checks and audits, demonstrating a reactive rather than proactive culture. The provider was receptive to feedback, took immediate action to address feedback from CQC and external agencies, and provided reassurances that concerns would be addressed. Evidence observed at this assessment identified that the governance system must become more robust and integrated into staff practices and culture. Staff reported feeling comfortable speaking openly, and they felt management would listen, although some staff felt their feedback about staffing levels had not been acted upon. Staff had received training in equality and diversity, and we saw evidence of some workforce inequality being addressed by the registered manager. People had access to healthcare support if required, and the management was working in partnership with external partners to improve communication and drive improvements. We received positive feedback from people and their relatives, saying they were very happy with the care. Whilst also acknowledging areas they felt could be improved.

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.

Staff were able to describe the service's direction and vision. However, we saw that this was impacted by the staffing levels, which did not support them in undertaking their role to the best of their ability.

We found the new care plan electronic system, implemented since our last inspection [published March 2023], evidenced a more task-led culture instead of the person-centred culture the provider wanted to achieve.The provider felt increased staffing levels and extra training would address these issues to ensure staff developed more personalised care plans.

The provider's website informed people what they could expect from living at Blackthorns. Phrases used included 'person-centred care' and a varied activity plan that provided residents with a rich and engaging lifestyle and a comfortable and welcoming home care environment in which to live. However, our findings at this inspection and feedback from visiting professionals, shows improvements were needed. Where we received positive feedback from relatives and people living in the service, their feedback also identified areas for improvement relating to the staffing, activities, and laundry. This showed the provider's vision was not embedded.

Staff were positive about the approachability of the registered manager, deputy manager and regional operations director. One staff member told us, "I am able to talk to all of them…I know they will always help." Another said they, "Would talk to any of them. Have spoken to them before, and they have always responded to general queries, they listen to you." Management told us how staff were valued and supported through regular 1:1 supervision sessions and career progression. However, some staff felt the staff rota was not always managed effectively, especially in covering planned annual leave and vacant positions, leaving areas understaffed, impacting their ability to fulfil their role effectively.

Feedback we received from visiting professionals, identified a shortfall in the leadership where a staff member was not demonstrating the same compassionate leadership as others. The registered manager told us this would be addressed through supervision and further training.

The providers’ information return (PIR) stated, “We value all our staff and are committed to recognising those who go above and beyond, so we choose to staff each month as our ‘gems’ of the month. They are awarded a certificate and gift to thank them and recognise their achievements.’

Staff felt they could speak openly with the registered manager. One staff member told us, "Management team are very supportive, the door is always open. I try and attend all the meetings and flash meetings we have. I like to speak up; I can speak, and they will listen. We can do it anonymously if we need to. A whistle-blowing policy is there if needed. I know where that is."

Some staff felt although they could freely speak up and the registered manager listened, such as staffing level concerns, they only sometimes saw any action taken.

The registered manager felt supported by the provider and comfortable raising any issues directly.

The provider had a range of forums to support people, their relatives, and staff in speaking up and sharing their views

This included meetings, quality surveys, complaints procedures, care reviews, and staff supervision. You said/we did posters with pictures showing what had been done were located in the service. Relatives told us they tried to attend the relative meetings, but they were held during the daytime when they were working. One relative mentioned, “I missed quite a few when [family member] first went in. However, I did attend a zoom call a few months ago. This was valuable and everybody got the chance to talk to other residents' relatives.”

Minutes from the relative’s meeting [May 2024], which 3 relatives attended, showed they were reminded about the registered manager's open-door policy and the provider's complaint policy. However, feedback we received from relatives showed that not all relatives were aware, with one relative saying, “I would not know straightaway, but I would find out via the Internet. I would hope to initially speak to the care home and resolve it.”

Management and staff told us how the provider supported their career progression. One staff member said, "They [management] always say come and say if you want training, and we can arrange that. They encourage us to attend more training."

The provider had systems and processes in place to promote equality and diversity. They were proud of their diverse workforce, which they felt fed positively into the service's culture.

Staff felt the new deputy manager, who had previously worked in the service, would complement the organisational structure and aid communication. The registered manager and regional operations manager were receptive to feedback. Although the management was proactive, any improvements needed to be embedded in practice to ensure sustainability.

We found the provider needed to have effective systems in place to independently assess, monitor and improve the quality and safety of the service; to ensure risks were mitigated. This assessment identified reoccurring themes from previous CQC reports in risk management, management oversight, staffing, pre-admission assessment, and person-centred care planning. The welfare visits carried out by the local authority showed where improvements made following feedback were not always maintained. The provider's February 2024 PIR told us the new electronic care planning 'ensures contemporaneous recording of the care delivered and aids us to maintain accurate information about our residents to enhance evidence-based person-centred care.' However, we identified shortfalls with staff maintaining accurate 'real-time' records and sufficiently detailed risk assessments. This showed the system for monitoring the contents of the electronic care plans was not effective enough.

People and their relatives told us they had access to other professionals in the community when they needed to support their health needs. This included community and specialists' nurses (Dementia, Stoma, Diabetes), GPs, hospital clinics, emergency services, dietitians, and occupational therapists. A relative told us they were kept updated on the outcome of any interactions, "I have had a couple of calls from them to let me know that they have had a doctor in to see [family member]." Where insufficient information had been given on hospital discharge letters or LA reports; it had impacted people's experiences when staff identified unknown care and support needs after admission.

The registered manager said they were part of a local authority project in collaboration with other registered managers. The project will give the providers a forum to discuss the quality of people's service plans. Information provided to the home by social care which providers felt could be more detailed.

They also told us about other work undertaken with partners as part of sharing and learning to drive improvements. This included linking with the NHS community education team, PROSPER (promoting safer provision of care for elderly) and the local authority training provider via the 'Innovation' team. They said it, "Enabled the staff team to access courses to support our residents safely as well as enhancing staff morale." Other work being undertaken to support people in interacting with the community included visits from schoolchildren so the children and people living in the service could show their artwork.

One professional told us the registered manager was, “Very good,” at engaging with them and their colleagues, and proactive in ensuring staff take up training opportunities. We also received feedback from professionals where they had to spend time trying to locate staff, including requesting support on a person’s behalf.

The provider was aware that improvements were still needed and they were taking action to address the shortfalls. For example, where the outcome of a safeguarding identified improvements were required in communicating with the community nursing service, action was being taken. This included meeting with the community matron, to improve communication between the services. This allowed any issues to be discussed and shared learning to support the service.

During our last inspection [published March 2023], the provider told us they were looking to introduce an electronic care planning system as part of driving improvements in recording/evidencing person-centred care. This had now been implemented. Staff carried handsets so they had direct access to people's care records and recorded what support they needed/were given in' live' time. We found the new system was not always meeting the provider's objective of evidencing individualised, safe, personalised care.

Although the provider was very supportive of the new electronic care planning system, they also agreed that, following social care professionals and CQC feedback, improvements were needed. This included improved auditing systems and additional training for staff in using the electronic care planning system.