Cornelius 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 good. At this assessment the rating has changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The provider’s values of empowerment and activity, personalised care, home environment, family involvement, strength-based approach, teamwork and supporting staff had been clearly embedded throughout the staff team and within the environment of the service. For example, people’s care documents were highly personalised, containing details about their characters, histories and the way like to speak from soft and gentle speech patterns to concise and direct. This approach helped people to feel heard, understood and gave staff the information needed to not only support their needs but also celebrate their lives. The environment was welcoming and homely whilst remaining clinically effective. A person said, “I chose everything in my room, it feels just like it should a home away from home.” These values formed the foundation of people’s activities, incorporating their strengths and interests whilst promoting physical and mental wellbeing. A person said, “The activities have raised my confidence and help me keep fit, there’s so much to do and I look forward to getting involved.” We saw staff adapting their approach and support, to each person’s needs throughout our assessment, reflecting the provider’s strength-based approach. People’s relatives feedback consistently praised the registered manager and staff for their prompt, open communication. A relative said, “[They always put [Loved one’s name] first, once they have her views, we give ours, they put people first.”

This was reinforced by the registered manager who fostered a culture of respect for both people being supported and between team members. A staff member said, “Everyone works together so well, it’s lovely here. I feel really supported [registered manager name] is easy to find, she’s visible on the floor and talks to the residents. Other senior staff are always there for us it doesn’t matter how busy they are.” This empowered staff to provide consistently caring support reflecting the provider’s values. Comments from people included, “I can’t fault anything they do.” and “Staff are so pleasant here, I’m very lucky to have found this place.” Staff described each person in detail underpinning their commitment to learn about the people they were supporting.

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 registered manager and senior staff team received consistent feedback from people, their relatives, staff and professionals about their ability to provide high-quality support in a caring manner. A staff member said, “[Registered manager’s name] listens and that’s the most important thing for me. For instance, I recently raised a concern for a person who wasn’t themselves, I told [registered manager’s name], and they went to see the person straight away. The people we support are her top priority.” Another staff member said, “I feel like I am included about decisions in the home and my opinion matters.” The provider responded to feedback about their digital self-developed care delivery system, from the registered manager and staff, and used this feedback to develop the system working collaboratively together. This helped promote inclusion and innovation within the team. Staff described the provider as present, accessible and regularly at the service, who were focused on providing people with high-quality care through supportive unpressured development within the staff team. comments included, “The extra support and training I received has given me the confidence I have now.” And “When I started here, I was surprised how often the owners came in. I get to see them a lot they’re so supportive.

The registered manager fostered and promoted inclusivity by asking for and listening to feedback from people, their relatives, staff and professionals at every opportunity. This was achieved through channels such as surveys alongside meetings in which residents and staff could share their ideas and views. A staff member said, “They have an open-door policy and they’re always approachable.” Whilst a person said, “Anytime I need to speak with staff and [registered manager’s name] they’re for me.” The registered manager spoke of the support they received from the provider, who had recently enhanced this support through the addition of weekly meetings with the registered manager, adding an additional opportunity to check in with each other.

Throughout our assessment we saw positive interactions between leaders, people and staff who spoke to each other in a professional manner. These interactions added to the homely and positive culture within the entire staff team helping foster an empathetic can-do problem-solving attitude which people directly benefited from. Staff were active in completing various audits reinforcing accountability within the team. A staff member remarked, “I do the first aid box audit, I check they are fully stocked and have the items needed to apply effective first aid.”

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

Staff described an open culture in which they were encouraged to speak up, supported by the provider’s policies including the whistle blowing policy and channels such as staff surveys. The registered manager was described as approachable and responded to concerns when raised. The registered manager sought feedback from staff in team meetings and one to one supervision. A staff member said, “I feel confident to raise issue if I need to, [registered manager’s name] takes them seriously and deals with them in a professional way.” Another team member said, “Our team meetings are productive, we talk about the things going well and suggest ideas about how to improve in other areas.”

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 registered manager had recruited a staff team aligning with the provider’s policy containing a diverse mix of backgrounds and cultures who came together as 1 team. A staff member said, “It feels like a big happy family here.” Another staff member said, “When I needed support [registered manager’s name] was there for me.” Staff received the training required to fulfil their roles. A staff member said, “After my induction and training I felt confident in my job.” The registered manager had created a rota which supported people living at the service and balanced shifts supporting staff to have periods of rest. A staff member said, “When I had a change in circumstances [registered manager’s name] supported me by making adjustments.” Staff described having the opportunity to develop in their skills and careers. A staff member said, “I’m being taught how to review care plans, there’s opportunity to develop here, they are very supportive.”

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

The structure of responsibilities was shared between roles, each accountable to the registered manager who had quality assurance processes in place to check the quality-of-care delivery. These included audits of people’s care plans, the home environment, staff training compliance among others. This meant areas of improvement could be identified and actions promptly taken. People’s experiences were central to the providers governance system which was built around and focused on people’s needs and outcomes. The system facilitated tracking of people’s experiences, helping leaders to identify and respond to changes in people early. For example, a person with a specific health condition, at risk of becoming socially isolated had changes made in collaboration with the person, to their support approach. The governance system was then used by implementing social engagement indicators, to track and evaluate the effectiveness of these changes.

The registered manager, with support from senior staff, carried out observations of staff competencies helping to ensure best practice across the staff team remained consistent. The registered manager was supported by additional audits of the service and care delivery carried out by the provider weekly, who then in collaboration with the registered manager created action plans addressing areas where compliance could be improved. All these processes and systems combined, helped leaders ensure information about how the service was performing and stayed up to date.

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 registered manager was active in forums where providers have the opportunity to share their experiences and learn from each other. Where appropriate, information about people was shared with professionals helping to make informed decisions such as changes to medication. The provider sought feedback from professionals, including GPs, in the form of surveys, providing opportunities to identify areas of good practice and other areas for improvement. When professionals gave guidance, this was incorporated into people’s care documents and had been shared with the wider team promoting consistent outcomes.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 their own digital care delivery system which they won a digital innovation award for. This gave the provider complete control over the development of the system enabling it to be shaped to suit the people they were supporting and respond to feedback from the registered manager around usability. The registered manager sought feedback from people in person, and through the provider’s channels such as surveys looking for ways to improve people’s experience. One example was when a person described the impact of hearing call bells was having on them, the provider investigated a silent call bell system and implemented this having a positive effect on the person and others’ experience. Other areas of the service had been improved following feedback from relatives around parking when visiting their loved ones, the provider responded by investing in the property redesigning the driveway to accommodate more spaces for visitors. An activity involving people and staff swapping roles had taken place; this immersive activity provided opportunities to see people’s experiences of daily life in the care environment from each other’s perspective, promoting improvement in quality of care by fostering understanding.