Belle Vue Country 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 requires improvement. 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.

At our last assessment we identified concerns regarding governance and oversight. During this assessment, we found improvements had been made. Auditing and monitoring systems were more effective, leaders had greater oversight of quality and safety, and learning was used to drive improvement. These changes demonstrated the provider had addressed the concerns previously identified under Regulation 17.
 

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 registered manager and provider demonstrated transparency with people and their relatives following our last assessment. Meeting minutes included where the management team shared immediate improvements and plans to improve. All stakeholders were invited to contribute towards change which was reflected in an open and inclusive environment.

A new digital sign-in system had been installed where visitors and staff would leave feedback in real time so suggestions would be received instantly. The registered manager reviewed the results, which so far had been positive.

The registered manager now documented their daily walk arounds and chose 3 topics a day to review. This promoted the smooth running of the service as well as to check staff practices making sure the service’s values were embedded.
 

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 registered manager had gained their registration with CQC since our last assessment and with the nominated individual had demonstrated a strong commitment to change and improvements. The nominated individual is the person responsible for the running of the service on behalf of the provider.

Staff were fully involved, onboard and invited to influence change, departmental meetings and staff wide meetings were held to openly discuss matters. A staff member told us, “Since your last inspection, we've all noticed many changes for the better. We had a staff meeting and the CQC report was extensively discussed. The management informed us about the changes that had to be done in order to comply with the rules and regulations and to improve our service. We all had contributions and many ideas were taken into consideration.”

The registered manager told us they were well supported by the nominated individual and their senior team within the service. The established supervision and champion system gave staff additional mentoring and encouraged capable leadership throughout the service.
 

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

Systems were now in place to support staff to speak up internally and outside of the service. Whilst previously staff had no concerns, they were not provided processes to speak up effectively. The freedom to speak up policy had been revised with guidance and contact details for external professional bodies. Easy to read leaflets and posters were also available for ease of access if needed.

Staff told us they felt free to speak up and express their opinions. The new supervision structure gave staff more opportunities to speak up if needed. The registered manager had an open-door policy and the nominated individual visited the service twice a week; staff said they were approachable.
 

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 felt respected, valued and included working at the service. A staff member told us how they supported newer overseas staff to adapt to the British culture which helped them to understand people’s needs, communication style and some cultural preferences.

Staff told us their shift patterns were tailored to suit their family lives. One staff member explained how they had been supported when their circumstances changed. They said, “I consider myself lucky to be a part of Belle Vue Country House. Following [leave], when I resumed back to work, I was given all the support and adjustments to maintain a healthy work- life balance. My duties were adjusted as per my needs, and I always felt that I am valued and my voice is heard.”
 

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.

Governance systems had strengthened since the previous assessment and supported improvements in the quality and safety of the service. The registered manager had reviewed their auditing processes and although they delegated some checking processes to senior staff and champions, they ensured to maintain a full oversight of findings. Outcomes from audits were reviewed, action plans were created and shared with staff to address shortfalls in a timely way.

Governance processes were effective; improvements were made throughout the service which covered all the shortfalls we identified at our last assessment. The registered manager told us they wished to progress with their advancements and shared plans of further improvements.

The registered manager told us, "Following our previous CQC inspection, we undertook a comprehensive review of our entire policy framework. Where appropriate, we consolidated related policies to improve clarity, reduce duplication, and ensure consistency across the organisation, all aligned with current legislation, best practice guidance, and CQC expectations."
 

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 and management worked in partnership with people, their relatives, staff and professionals. They sought feedback and acted upon suggestions and comments. The community was brought into the service by open visiting hours for friends and families and local entertainers. The registered manager shared plans of trips out which were to be arranged imminently.

Visiting professionals held a key role in people’s treatment, staff liaised with them, provided feedback on treatment, documented and followed their advice. A visiting healthcare professional commented, “I have a great relationship with the staff, including [registered manager] and [deputy manager], who are always open and transparent with me. All staff make me feel welcome and there is always a calm atmosphere amongst the staff who all greet me and are friendly.” And, “[Registered manager] and nursing staff will contact me by e-mail to refer their new residents, during visits all staff work well with me and are instant at updating resident’s care plan’s following my recommendations.”
 

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 management were on a continual learning journey. Many told us they had gained a deeper understanding of how to provide a quality service. Comments included, “I'm proud of how far we have come and hopefully you will see the progress we have made. We had meetings about our documentation which let us down last time, but we do care a lot here and hopefully this shows.”

The registered manager had worked with other bodies, including relevant fire safety professionals, specialist contractors and the local authority; they signed up for updates to keep informed of changes to practice guidance. The registered manager attended seminars and networked with other registered managers to share learning and ideas. They gave examples of where they had learned from others and where they had shared their own ideas.

The registered manager told us, "I am trying to embed a learning culture and include any updates from CQC and Skills for Care etc. I will send the templates and leaflets to the care staff and nurses. In the morning handovers I ask them questions, initially I was circulating but they were not reading. Now I check their knowledge."