The Coach 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

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 now well managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 management team promoted service values through discussions with staff in supervisions, regular staff meetings and through surveys. The values of the provider focused on professionalism, honesty, openness, competence and kindness. Staff spoken with explained clearly how those values underpin their approach to providing care and support to people. One staff member said, “We talk about our culture and how we want to support people. [Provider] have the shared values that we all work to show. Of all of them I would say that honesty and being kind are the most important and how I want to be seen to work.” People’s feedback about staff and managers and our observations through this inspection confirmed these values supported a shared, open culture within The Coach House.

The provider had exceptionally inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

The provider drove continuous improvement by embedding learning and reflection into everyday practice. They did this through using performance data, staff feedback and people’s experiences to strengthen care. The Chief Executive visited The Coach House during our inspection and was comfortable engaging with people about their day. They knew about those people, their struggles, their successes and were at ease in their discussions. There was a sense of balance and equality within those relationships where The Chief Executive valued those times to understand how their management of the organisation filters down to the people using the service. We observed a genuine level of transparent communication with people that informed the clear expectations they held of staff and managers. This, combined with compassion and accountability, inspired staff and consistently sustained high standards across the service. Staff told us they felt supported by the management team and there were opportunities to share information to ensure people received care safely, this included regular staff meetings and daily handover meetings. The registered manager and deputy manager were very involved in the day to day running of the service and were passionate about the people who received their support and care. One staff member said, “Managers are honestly open, that is the best way I can describe them, always open and honest always open to challenge. They will welcome any suggestion which is reasonable.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The service had a whistle blowing policy in place and was prominently displayed for ease of access which incorporated a confidential dedicated phone number displayed for staff to raise any concerns. Staff had opportunities through meetings, supervisions, contact with the management team and senior managers to share their concerns. One staff member told us, “We have reported times when we have not worked as a team which is causing a blockage and affecting the residents. We sat down in a reflection, divide the tasks equally, talk about what has gone wrong and it has really helped the shift and the team.”

Staff we spoke with told us they were confident to raise concerns with those managers but would not hesitate in reporting externally to CQC or the Local authority if needed.

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.

The Coach House employed a diverse workforce. Mandatory equality and diversity training was in place for all staff, with refresher training to maintain awareness of protected characteristics and discrimination.

Staff had the opportunity to discuss their wellbeing, job satisfaction and any support they required within their supervisions, team meetings and had access to an external staff helpline. This supports staff in areas such as personal problems that might negatively impact their work performance, their health or wellbeing.

Staff shared various examples of how they had been supported when they had requested flexibility in their working arrangements.

Any assistance staff required to support them to manage their work life balance and health were discussed with the management team. We saw how the registered manager sensitively supported a staff member during this inspection with accommodating a change in their personal life which affected their work availability

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider used a range of processes to maintain oversight and to monitor the quality of the service provided. There were scheduled audits of key areas to monitor and oversee risks to people within the service. Senior managers reviewed those audits and incidents accordingly. The registered manager delivered a quarterly report to the senior leadership team that reported on areas of risk, improvement, emerging trends and the measures in place to manage those. The results of these audits, actions and improvements were documented within various action plans. The provider had identified the need to employ a quality manager who would then visit each service to visually audit and monitor compliance with those identified improvements. This role would increase the scrutiny of monitoring of not only the quality and safety of care but provide assurance that there is an independent assessment completed outside of the registered manager.

The improvements we identified during this inspection were welcomed by the management team as a learning process. They shared the feedback with staff and immediately took steps to organise required training and additional support with keywork for staff. We felt assured from the management teams open and transparent approach that these actions would be completed in a timely manner.

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.

Managers and staff were open and transparent, and they collaborated with relevant health professionals and agencies in this manner. Staff continued to strengthen community links to ensure the service continued to develop and provide positive outcomes for people. This included developing links to meet people’s cultural needs and enhancing access to the local community for people.

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 had developed a culture of learning and improvement that improved outcomes for people. Learning was shared openly with managers from all of the providers other services through a monthly quality meeting. Managers discussed risks and improvements either from other services or from nationally reported incidents. We saw 1 meeting discussed a significant choking episode, which was discussed and then fed back to staff for shared learning. Staff benefitted from a reflective approach through supervision, team meetings, reflective sessions and training. This approach ensured learning was embedded at all levels and used constructively to improve care, rather than attribute blame.