Sowerby House

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

We identified a breach of legal regulations. Systems and processes to assess, monitor and improve the quality and safety of the service were either not operated effectively or were not in place. The provider failed to ensure good governance systems were used effectively to assess, monitor and mitigate the risks to people, maintain accurate or up-to-date records of people's care or the management of the service. There was no evidence of continuous learning or systematic approach to improvement. Incidents were not reviewed for themes, patterns or for lessons that could be learned.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff did not have a clear awareness by of the organisational values expected of them. However, staff had a clear understanding of what constituted good care. One staff said, “We treat everyone the same, some people may require adjustments and support to achieve this, so we tailor their care on an individual basis to achieve good outcomes for them.”

Whilst the provider and both managers described to us some actions they were planning to take to make improvements, action plans did not always include up to date information to support service improvement. The provider had recently recruited an operations director who was providing resources and additional support to the service.

We observed team focused interactions with a dedicated staff team working together for the benefit of the people’s health and well being. Staff told us the service was well manged. They discussed the improvements made and in progress by the registered manager which were beneficial to their working and personal lives. The registered manger was passionate about supporting people to live their best lives and discussed a number of changes they had implemented to empower staff to help achieve this.

There was a registered manager in post since 2022. The registered manager completed relevant statutory notifications. The manager was supported by the provider’s regional management team. The regional manager reviewed audits and carried out their own checks of the service. They provided regular on-site support.

Staff felt supported and respected. Staff were aware of whistleblowing and told us they felt able to raise concerns. The registered manager told us they had an open door policy, completed daily walk arounds and spent time talking with residents and staff to promote a positive culture.

Policies were in place to guide staff on how to raise concerns.

Staff spoken with told us managers of the service were flexible in their approach to meeting staff needs and requirements.

There were systems in place to enable the provider to identifying staff’s equality, diversity or inclusion needs. Sowerby House had won an award at a ceremony held by the provider for work around raising awareness of other cultures. Recruitment files included equal op monitoring, health declaration and working time directive.

Care records were found to be inconsistently completed. There was no system in place for ensuring people received person centred care. Staff told us they were informed of any areas identified for improvement through regular staff meetings.

Systems and processes to assess, monitor and improve the quality and safety of the service were either operated effectively. A range of audits, governance and oversight systems had been in place, but they had been used effectively to identify issues or take action to improve. They had not identified concerns found during this assessment. We reviewed the audits completed by the registered manager. Whilst systems were in place to oversee the service, these were not wholly effective in identifying risk or improving the service. For example, falls and weight audits completed did not contain actions taken by the provider to mitigate any further risks. There was no effective overview or review of accidents or incidents for themes or patterns or for lessons that could be learned. There was no evidence of audits or checks on the recruitment process. The provider had a checklist in place that identified the required checks and documents. Internal audits had not identified that these had not been completed or that the required checks had not been undertaken. There was no system in place for ensuring people received person centred care. There was no formal oversight of activities on offer for people or information about how people's preferences were being met. There was no plan in place to improve activities. Medicines were not being managed safely. Systems that were in place for the oversight of the premises and equipment had failed to ensure action was taken to ensure health and safety and maintenance checks were completed.

People we spoke with were mostly complimentary about their relationship with staff and managers, but they were concerned about the recent turnover of staff and managers.

Some staff spoken with expressed concerns about the recent turnover of staff. Registered manager advised they had worked to improve the relationship with district nurses and worked hard to improve that.

There were a number of health and social care professionals involved in people’s care to ensure the care they received met their health needs. One professional said, “Residents seem happy. Staff seem to listen to our advice. It is a busy home. [Registered manager] is always responsive to our feedback and recommendations.”

The local authority quality team asked the registered manager to give a speech at a conference about the positive impact hydration stations had. The registered manager shared they had reduced falls, encouraged staff knowledge and reduced risk of infection.

The registered manager gave examples of where learning has been considered. For example, changing times of shifts following feedback.

There was little evidence of continuous learning or systematic approach to improvement. Themes and trends were not identified through systems currently in place. Weight records were not always reviewed effectively, where weight loss had been recorded.