Eden Grange

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 and senior staff to deliver personal care to people they supported in line with the provider’s values and culture. A member of staff told us, “The services culture has significantly improved since the [name of registered manager] had been in day-to-day charge. I think we’re starting to work better as a team now and staff morale is a lot better these days. As a care home I think I can safely say we’re all beginning to move in the direction as one, joined up team.” 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 care home had an experienced registered manager in post who was supported by a deputy manager, nurses and team leaders. The managers told us they had also recently recruited a new clinical lead nurse. The feedback we received from people about the approach of the services management team was positive. A relative said, “I have a lot of time for the managers here who do a good job running the home.” Staff were equally complimentary about the leadership style of the management team who they consistently described as effective, professional, and approachable. A staff member told us, “I like the way the manager [registered] and the deputy manager run the home. I personally get on extremely well with both of them. They are always on-hand to offer advice and support.” Another staff member added, “The manager [registered] is firm, but fair. We’ve had a few ‘wobbles’ here in recent years, but I think the current managers are slowly turning things around for the better.”

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

There were systems in place to enable staff and others to speak up when they felt something was wrong or could be improved. Managers promoted a positive and open culture where people felt they could speak up and have their voices heard. People expressed feeling able to raise any concerns they might have and were confident their views would be taken seriously and acted upon.

Arrangements were in place to investigate complaints, supported by a complaints procedure that set out how concerns would be handled and what people could do if they were dissatisfied with the response. The providers complaints and staff whistleblowing procedures were accessible and set out clear expectations for how concerns should be reported and dealt with by the provider.

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 provider had arrangements to support equality, diversity and inclusion. Equality and diversity policies were in place to ensure staff were supported to work in an environment that was free from discrimination. Staff had opportunities for career progression 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 in the workplace.

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

The providers governance systems were effectively operated. The provider used a centralised electronic monitoring system to record and review key data and were able to identify any themes and trends developing. The provider’s quality and governance team ensured appropriate action was taken to learn from any events or incidents that occurred.

Managers and staff regularly undertook a range of quality monitoring tasks including, daily walking tours of the care home to observe staffs working practices, gathering people views in relation to their experiences of living, visiting or working in the home and constantly reviewing accident, incidents and complaints. Managers and staff held regular meetings to discuss and analyse their findings, identify themes, learn lessons and agree action plans when areas for improvement were identified.

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 worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service demonstrated effective partnership working. Managers and staff engaged proactively with relevant community-based health and social care professionals and organisations, with established systems for regular sharing information and learning. The service had established positive working relationships with multiple community-based health and social care professionals and agencies including pharmacists, physiotherapists and end of life care/ hospice services. Staff reported good access to advice and support from community professionals when required.

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 a willingness to innovate and develop the service when they introduced an electronic system to improve how they managed care plans and medicines, and monitored the quality of service they provided. They conducted a range of audits and obtained feedback from stakeholders. They responded to the outcome of these and made improvements to the service when needed. When lessons needed to be learnt, the provider developed time specific action plans which set out clearly what actions they needed to take to improve. Managers and staff regularly met to discuss how well the service was meeting different standards of care. Staff undertook regular training and were given information about good practice and legislation.