Coalway Lane

Since the last rated inspection, in 2018 and targeted inspection looking at infection control practices in 2022, the organisation has changed its name to Everyturn and there has been a change of manager. We completed this inspection because of the length of time, which had elapsed since the last full inspection was completed.

People found they were treated in a non-judgemental way and supported to reach their full potential. People discussed how staff had enabled them to deal with recent crises in their lives and supported them to take steps to return to living independently. The nature of the service meant staff deployment needed to be very flexible. Overall, there were enough core staff in place to ensure people’s needs were met and, when needed, additional staff could be readily obtained. The management team were currently completing a comprehensive review of the staffing tools they used to ensure they are sensitive to the flexibility of the service needs.

Staff worked closely with the crisis team and hospital staff teams to ensure people were only admitted when they were confident the service could meet the individual’s needs. Staff understood people's needs and how to manage any presenting risks and the assessments assisted staff to identify how to mitigate risks.

The clinical team had developed a comprehensive induction tool, which all staff working in the service were to complete. This included any new staff, agency staff and auxiliary staff who routinely worked at the service. We found this would effectively assist all staff understand the needs of people and any potential risks.

The provider’s ‘people team’ had ensured a robust training programme was in place. They constantly evaluated its effectiveness; in terms of the impact it had on how staff delivered the service; if it assisted staff to effectively support people to improve their mental health and whether it had assisted the organisation to embed the overriding cultural principles of ‘Here so no one struggles alone.’ The provider valued the diversity within the team. When this was going to be adversely affected because of a change in requirements for international workers the senior management and Trustees proactively changed their minimum pay scales. The People’s director is actively engaged in discussions with the government about salary sacrifice schemes and measures which would make sure there was equitable access to benefits.

The Trustees, senior managers, quality and safety team, clinical leadership teams and management team within the service constantly reviewed the operation of the service and actively made changes as and when these were needed. The empathetic, caring and person-centred approach demonstrated by senior leaders had filtered down and influenced the manner staff worked within the service. Their interactions were based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and the community.

The provider had created a new governance department, and they had ensured robust quality assurance measures were in place. The quality and safety team had designed systems that readily assisted them and the staff to manage and deliver good quality, sustainable care, treatment and support. They continuously looked at the systems to see where enhancements could be made. Routine service reviews were completed, and these had been nuanced to suit each location. Both senior managers and trustees took part in these reviews and completed listening exercises with people who used the service.

Assessments were completed in a timely manner and were accurate. Staff actively used these assessments to understand people’s ongoing needs. The actions staff took from these assessments had led to a very positive outcome for people and the reduction of their distress.