Pendene 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 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.

The vision and values of the service were clear, person-centred and included honesty, involvement, compassion, dignity, independence, respect, equality and safety.

People’s feedback was consistently positive about the service.

Staff we spoke with felt the service was like a home (not a care home) and that they were one big family.

People were at the heart of care and support provided. Staff were motivated to achieve good outcomes for people and improve their quality of life.

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 did not have a registered manager in post at the time of the inspection; however, the provider was in the process of submitting an application to take on the registered manager role. The previous registered manager had changed role to quality monitoring, and a new care manager role was being created to support the management team.

People, relatives and staff praised the leadership team and found them approachable and supportive. A relative said, “It’s managed 100% well. I can’t fault that care home at all. The whole thing is professionally done. They are absolutely fabulous and it gives me a lot of comfort to know [family member] is safe.”

Staff said they were supported by managers and by the team. They prioritised safe, high-quality, compassionate care.

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

The provider had a policy about speaking up. Staff understood their responsibilities and felt confident action would be taken, and their voices would be heard.

Managers encouraged staff to raise concerns and promoted the value of doing so. Staff and leaders acted with openness, honesty, and transparency. Staff explained they felt able to offer challenge and hold each other to account in a constructive way. A staff member told us they would point out if a colleague was not doing something right and take them to the side and highlight this to them. If the situation persisted, they would refer their concerns to the manager to follow up.

The provider understood their responsibility to be open and honest if things went wrong.

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.

Diversity and inclusion were valued in in the workforce. Staff told us they felt supported and described reasonable adjustments made to accommodate their needs.

Human rights, equality and diversity issues were included in staff training. The provider told us they had a non-discriminatory recruitment programme which had resulted in a diverse staff group.

Leaders supported work towards an inclusive and fair culture by improving equality and equity for staff.

Staff felt empowered and were confident their concerns and ideas resulted in positive changes to shape the service and create a more equitable and inclusive organisation.

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 had effective systems of accountability and good governance. Risks were identified and monitored. Audits were carried out to ensure staff were delivering care and support to expected standards of quality and safety. Where risks were identified, additional analyses were carried out and action was taken to reduce further risks and make improvements.

The voice of people who used services was represented in governance and decision-making structures at appropriate levels. Action was taken in response to feedback received through people and staff surveys. The provider had a business continuity plan for staff to follow in the event of any incident or emergency.

Notifications were consistently submitted to external organisations as required and the provider responded to any safety or quality requirements appropriately.

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.

We reviewed the provider’s actions taken in response to external inspections and recommendations such as the local authority, the fire service and pharmacy. We found the provider was responsive and took swift action, when required, to achieve compliance.

The provider told us about activities available in the local community such as shopping and eating out. However, some people told us they would like more opportunities to go out.

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.

Staff and leaders had a good understanding of how to make improvement happen. They made sure people using the service, their families and carers were involved in developing and evaluating improvement and innovation initiatives. Following satisfaction survey responses, the provider offered activities requested such as games, arts and crafts and massage.

Staff told us good practice was always encouraged and acknowledged. They were encouraged to speak up with ideas for improvement and innovation. A staff member told us, “Management are always open to suggestions as long as you stay within rules and regulations, you are listened to.”