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

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 71 (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 manager and staff understood the provider’s vision and values to provide good quality care, with supporting policies and procedures. The manager demonstrated a positive approach to continuously develop the service to ensure people remained at the heart. When asked about the vision of the service, the manager told us, “Being diverse, treating everyone as an individual, communication is key, being open and honest, welcoming all cultures and adapting. We celebrate every celebration and accept everyone's culture.” At our last inspection staff were not fully clear in their roles and responsibilities which had created a poor culture of learning and a lack of reflective practice. Significant improvements were observed and evidenced during this inspection. Staff were observed to work well as a team and were knowledgeable and knew people well. The atmosphere in the service was relaxed and welcoming. One staff member said, “I think the home has progressed so much in the last year; the teams work very well together; there were a lot of issues that needed changing, and we have worked very hard to make this a better home for the residents.”

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 management team were open and honest during the assessment about the failings at the previous inspection and the steps they had taken since the appointment of the new manager. The manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where needed. Staff were positive about the support they received from the management team. One staff member told us, “Since [manager] has come it is very nice. I enjoy my work now. Wherever and whenever we need [the manager] they are available.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The manager was open about lessons learnt and actions taken to prevent recurrence. They understood duty of candour and their responsibilities. The management team were visible and had an open-door policy to ensure people, relatives and staff could provide feedback or raise concerns. There was a culture where staff felt safe and confident to raise concerns. When asked if they felt the manager would respond to concerns raised a staff member replied, “Yes, 100% [the manager] would address that.” Another staff member said, “They [management] are easy to talk with.”

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 an equality, diversity and inclusion policy. Regular staff meetings were held with each of the staffing groups to share their views and experiences and for the manager to cascade information about things happening in the service. Staff meeting minutes were maintained to ensure that all staff had access to the information they needed. One staff member told us, “I do think the environment here is so pleasant; diversity is celebrated. Teams are fantastic and [there is] diversity of staff and residents.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. At our last assessment we found the provider needed to make improvements to their governance systems. At this assessment we found improvements had been made. There was a comprehensive system of audits, quality assurance checks and care delivery reviews in place. However, while medicines audits were completed regularly, they failed to identify some of the issues raised during this inspection. The manager told us the service had taken action to make improvements and there were plans in place to address others.

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. Staff worked closely with external health and social care professionals to ensure people’s individual care and support needs were fully known, understood and met by staff. This included healthcare professionals and the local authority. The management team told us stakeholders were encouraged to contribute through shared information and learning with partners to drive improvement. One partner told us, “Staff are receptive to information and recommendations made.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. The provider had a service improvement plan which was regularly reviewed and updated. There was evidence of positive changes that had been made to the service to make improvements since our last inspection. Comments from relatives included, “The care is 1000% better than last year and all the family feel that we are amazed on how much it has changed and improved, very pro-active now.” Staff told us of the new systems that had been introduced which were proving useful, for example detailed handovers for staff when staff came on shift to ensure they were aware of any changes. Staff confirmed that the management team were organised, and they visited out of hours to audit night care and meet staff as well as during the day. One staff member said, “The new manager has made lots of changes which are better. Like we get more training; we get more support from the manager if we have problems with the shifts. New equipment like hoist batteries and new mobile phones. New slings since new manager came in. This makes it better.”