Peacemills 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

Governance arrangements in place were not always effective which meant there were missed opportunities to drive service improvement. The management team and provider had had clear oversight of the service however more timely action was needed in some areas to ensure the safety and quality of the service were maintained. The management team were open and honest and were receptive to feedback which ensured there was a positive culture. Managers promoted equality and diversity which meant Peacemills was a happy place to work and live. The registered manager was aware of the regulatory requirements and submitted notifications as required.

This service scored 75 (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 processes in place to ensure there was an open and honest culture. The management team had an open-door policy and all of the staff we spoke with confirmed this policy to be accurately in place at Peacemills. The operations managers completed audits to ensure staff worked in line with the values of the home. During our visit the management team were receptive to our feedback and acted to ensure people received safe care and support. An equality and diversity policy was in place which included all protected characteristics and staff were aware of where policies were stored and read these as part of their induction.

Staff and the management team told us there was an open and honest culture at Peacemills. The management team were transparent throughout the assessment and discussed the recent concern and the action they had taken to ensure all staff were empowered to raise concerns if needed. This included re-informing all staff of the internal and external whistleblowing process including the display of a simple to use diagram of key people to contact. Staff told us there was a positive culture at the home. Staff told us they worked hard to ensure Peacemills was a positive place to work which ensured people received good care from kind staff. Staff said, “Staff morale suffered during Covid, but we have worked to build it back up and as such we have a great team of staff.” People were supported to be part of the community and we received feedback about church groups people attended.

The management team which included the registered manager and manager were established and had worked at the service for a long time, they knew people well and spoke with passion about the care and support they wanted people to receive. A newly appointed deputy was in place to support the management team. The registered manager told us the provider was approachable and kept in close contact to ensure Peacemills ran smoothly, they felt empowered and supported to complete their duties. Staff told us the registered manager and manager were approachable and present in the home. Staff said, “I feel very confident to approach or report any issue to the management staff of Peacemills, any issues are treated with strict confidentiality and they have proved that to me. One of the management team are always available and participate in the day to day running of the home.”

The management team were experienced and capable, the manager had received extensive support from the registered manager to ensure they carried out their duties effectively. We found some areas which required further work to develop the service. The management team were aware of these issues prior to our visit but had not always acted in a timely manner to rectify issues. For example, the issues relating to risk assessments as detailed in the Safe section of this report had been known about for a long period of time, but minimal action had been taken. This meant there were missed opportunities to drive service improvement.

Policies in place meant staff were supported and encouraged to speak up when needed. Regular meetings were held and recorded to allow for staff not able to attend to review the content. Actions of meetings were documented to ensure any action needed was completed. Advocacy services were displayed for people to utilise if needed. This meant both staff and people had accurate information to speak up if needed. Residents and relatives’ meetings were held for people and their families and representatives to raise any concerns they might have in a safe environment. The process to ‘Speak Up’ was clearly displayed upon entry to Peacemills, the use of alternative communication methods such as images supported people, staff and visitors who may not be able to understand standard text. This meant people were provided with information in a format they understood. People were provided with the complaints process when moving into Peacemills.

There was an open culture at the home which encouraged staff, people and visitors to speak up when needed. Staff unanimously told us the management team were approachable and felt confident they would act on any concerns raised. We received some concerns prior to our assessment of Peacemills in regards to freedom to speak up but did not find any evidence to support these concerns. Staff told us, “I feel confident to report any issues to the management team, they listen when issues are raised.” The operations manager recently visited Peacemills to ensure staff were empowered to raise concerns staff were given the opportunity to speak with them or raise concerns anonymously and no staff raised any concerns during this time. Staff took part in meetings and were supported with supervisions to provide them with opportunities to raise concerns in both a group and individual environment.

Processes in place meant all staff were included to contribute to the running of the service. The management team ensured staff were fully informed of their roles and rights. For example, during team meetings the care manager delivered mini training sessions to ensure staff were confident in their roles. An equality and diversity questionnaire was completed as part of the recruitment process. This meant there was a diverse workforce which was reflective of the local community. Staff were supported to progress within their chosen career. We found many staff to have been mentored and coached and had progressed to more senior roles at Peacemills. This meant there was a stable core staff team in place for people living at Peacemills.

Staff told us they felt valued and supported in their roles. There was a diverse staff workforce at Peacemills all of whom told us they were supported by the management team. Staff said, “I look forward to my shifts at Peacemills because the environment is very welcoming.” Another staff told us, “All staff are treated equally no matter what your job role hence why I have worked here so long.” Staff were supported by both an equality and diversity policy and training. The management team spoke with pride of the whole staff team and reflected that their hard work made Peacemills a positive place to work.

Staff were clear about their roles and responsibilities. All of the staff we spoke with told us they felt supported by the management team and said they would act on any concerns to ensure people received safe care and support. Staff said, “The managers are present, and I have approached them on several occasions. They do have listening ears and act swiftly addressing any issues brought to their notice. They are attentive and supportive.” The registered manager and care manager were aware of their regulatory requirements and responsibility under the duty of candour. Duty of candour is a professional responsibility to be honest with people when things go wrong. The care manager had applied to become registered with CQC. They were open and honest throughout the assessment process. The registered manager and care manager displayed positive attitudes to the assessment process and were responsive to feedback.

Governance systems in place were not always effective. Audits were completed and some detailed what action was needed. However, we found several inconsistencies during this assessment as detailed throughout this report which had either not been identified or identified and not yet addressed. This meant processes in place did not always promote service improvement in a timely manner. For example, we found several inconsistencies in care records which has not been addressed. We also found many people without a call bell had not been identified prior to our visit. We fed this back to the management team who told us they would take immediate action. Audits relating to the environment had been completed with clear actions documented. Clear roles and responsibilities were documented to ensure the management team knew who was responsible to complete any actions identified. Policies were in place to ensure staff knew how to perform their duties in line with guidance, legislation, and the provider’s own ways of working. Emergency contingency plans were in place to ensure staff had guidance in the event of an emergency.

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.