Devonshire Dementia 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

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 good. At this assessment, the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 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.

Staff were supported by managers to deliver consistently safe, person-centred, and inclusive care and support to people in line with the provider’s vision and values for the service. The provider supported a reflective practice approach, establishing a learning culture to support staff to deliver good quality person-centred care. A staff member told us, “This is such a wonderful place to work. We have an excellent team spirit and culture here. There remains a strong emphasis on treating each person who lives at the care home as an individual with unique needs and likes.” Systems and processes had been designed in line with this vision and focused on people and meeting their individual needs. The managers routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles.

The provider had 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 did so with integrity, openness and honesty.

The service continued to have a stable management team in place. The registered manager, deputy manager and team of assistant managers were all experienced in their role. They had appropriate expertise, supported staff well and ensured care delivery met professional standards. They promoted inclusivity and openness, ensuring staff felt comfortable raising concerns or seeking advice, reflecting a supportive leadership style that encouraged transparency and wellbeing. Staff confirmed this approach, noting they were always able to speak openly with management and share their ideas which were listened to and acted upon. A staff member told us, “The managers are so approachable and supportive here. They always listen to what we have to say and take our views seriously. We are valued and made to feel part of one big team.” Relatives were equally complimentary about the leadership approach of the services managers. They expressed confidence in the entire management team, describing consistent communication and saying that any issues were addressed quickly.

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

People expressed feeling able to raise any concerns they might have and were confident their views would be taken seriously and acted upon. The provider had an accessible complaints and staff whistleblowing procedures in place, which set out clear expectations for how concerns should be reported and dealt with by the provider. Staff confirmed they could submit daily shift evaluations anonymously through a letterbox or digitally. Managers told us staff have regular opportunities to express their views about the care home through remote, online meetings.

The provider valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who work for them.

The provider supported staff fairly and promoted an inclusive working environment. Policies reflected equality and diversity principles, and managers ensured staff needs were understood and accommodated. Staff reported feeling valued and treated fairly. A staff member told us, “I feel respected and valued by all the managers and colleagues I work alongside in the home.” Staff had opportunities for career progression, were offered flexible work options and had their diverse cultural and religious needs respected. Staff were also supported through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace. Managers and staff confirmed it was mandatory for them to routinely receive equality and diversity, and LGBTQ awareness training.

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’s governance systems were effectively operated. They were conducting regular audits and reviews in relation to the quality and safety of the service people received. In addition, managers from the provider’s quality and compliance team routinely visited the care home to conduct their own internal audits. The outcome of all these checks and audits fed into the providers centralised electronic systems which recorded and reviewed all the key service data, to identify themes and trends which might emerge. Managers and staff held regular meetings to discuss and analyse their findings, identify themes, learn lessons and agree actions they needed to take to address any gaps in performance and improve.

Managers understood and demonstrated compliance with regulatory requirements. They also understood their responsibility to provide honest information, suitable support and to apply duty of candour where appropriate.

The provider understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Managers and staff confirmed they worked in close partnership with multiple community-based health and social care professionals and agencies who they regularly consulted, and shared information and learning with. A manager told us they always welcomed the views and advice of other community-based care professionals including, GPs, district, tissue viability and palliative care nurses, nutritionists, speech and language therapists, and dentists. The provider had also joined various new initiatives and pilot schemes that looked a new and more effective ways to respond to the needs of people living with dementia. This helped the provider with their partners continuously review and improve their practices.

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.

Systems were in place to review performance, identify learning opportunities and adapt practice. The provider demonstrated willingness to innovate and develop their service and systems. The provider routinely analysed the outcome of audits and checks they regularly conducted to identify performance shortfalls and learn lessons. When lessons needed to be learnt, the provider developed time specific action plans which set out clearly what, how and when they needed to take steps to improve the service they provided people. Staff confirmed information about any lessons that needed to be learnt and changes to policies and procedures were regularly shared and discussed with them at individual and group meetings.