The Grove -4

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 inspection we rated this key question Requires Improvement. At this inspection 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.

Governance measures and audits were not always effective in monitoring the quality of the service and implementing and making improvements where necessary. However, there was a positive culture at the service. People were happy with their support and enjoyed living at the service. Staff enjoyed working at the service and felt well supported. There had been improvements at the service since our last inspection.

This service scored 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager had a shared vision, strategy and culture. The culture at the service was mostly positive. Staff understood their main role was to support people to live their lives the way they chose to. The registered manager had clear visions and a direction for the service and shared this with the staff team. They were working hard to continually improve the culture at the service and further improve people’s experiences. They had taken steps to personalise the service for people and had encouraged and supported staff to help people have more freedom and choices in many areas. For example, people’s access to the kitchen and garden area was no longer restricted as it had been in the past. The service felt homely, and people were happy and relaxed being supported by the staff team. Staff respected the service as people’s home. People approached staff for help when they needed this and were reassured when staff supported them. A relative said, ‘‘I think generally speaking [family member] is very well supported. Like every service there are ups and down, but it is mostly up, and the downs are dealt with quickly.’’

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. Staff told us the registered manager was approachable and included them in discussion about the service and how best to support people. The registered manager was capable in their job role and had oversight of the service. They understood their regulatory responsibilities and took action to improve where necessary. The registered manager was a part of the staff team and were very visible at the service making sure they spent time with people and the staff team. The registered manager's office was always open, and people were able to enter and speak with them when they chose to. People were happy and relaxed doing this. A relative said, ‘‘[Registered manager] is really good and is making a real positive difference at the service. They are very approachable, want what is best for people and will always get back to me. It feels like things keep getting better.’’

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a complaint and speaking up policy in place at the service. Where people had raised concerns in the past these had been looked in to and addressed promptly. Staff told us they knew how to raise concerns and felt comfortable and confident in speaking up at the service. Information about how to raise concerns was available for people in different formats. Some relatives told us that in the past they had not really been asked for their opinion on their loved one’s support and in some cases had not seen a copy of their family members care plans for long periods of times. However, they told us since the new registered manager had started in post this had improved greatly.

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. Staff told us they enjoyed working at the service and felt well supported by the management team. The provider supported their equality and wellbeing by offering preferred working patterns and discussing their job roles with them regularly. The providers recruitment process was fair and equitable.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Whilst audits were being completed at the service, these were not always effective in identifying areas where improvements could be made. For example, in areas such as medicines, noting when updates were needed to people’s care plans or if new guidelines were needed, staff engagement with people at key times of the day and how people were being supported to discuss and achieve what was important to them. Some audits had been completed which identified areas for improvement, however actions were not put in place to start work towards these.

However, other audits and governance measures at the service such as health and safety audits were effective. There was a continuity plan in place to effectively deal with an emergency situation at the service. A relative said, ‘‘From my point of view it is all going very well and [registered manager] seems to be on top of everything.’’

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 management and staff team had good working relationships with partners such as health professionals and local authorities. Staff had started to support people to be a more active part of their community and follow their interests and past times. People went shopping and attended local establishments such as restaurants and other areas of interest on a regular basis. The registered manager had enabled people to go out with staff during the day as a ‘personal day’ whereas in the past people had attended a local day service every day. This had a positive impact for people who looked forward to their ‘personal days’ and we saw evidence of how much people enjoyed what they got up to on these days. Staff also told us they were being encouraged to support people out into the local community more often. A relative told us, ‘‘I think staff try their best to get out as much as possible. [Registered manager] has also supported [family member] to come and visit us which has been great and something we have not been able to do for a little while.’’

The provider did not always focus on continuous learning, innovation and improvement. The management team had improvement plans in place based on findings from internal and external audits and findings, however actions from these were not always recorded or worked on to help improve the service. Whilst there have been improvements at the service since our last inspection, there were still areas where improvements needed to be made, as identified throughout this report. Some areas such as staff deployment and care plans not containing updates and guidance where necessary were known by the registered manager and provider, however effective action had not been taken to drive improvements.

However, the registered manager was receptive to the feedback at this inspection. They had already started, or started to begin work on the areas for improvement we identified and discussed during the inspection. People were being supported by the staff team, and relatives told us they felt the service had and continued to improve. One relative said, ‘‘I do feel the staff team want what is best for people. There is always room for improvement but as a whole I think [family member] is happy and that’s the main thing.’’