Maiden Castle 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 inspection we rated this key question good. At this inspection 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 service 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 provider and registered manager had a clear vision for the service which aligned to the service values which were, honesty, excellence, approach, respect and teamwork. Everyone understood the shared values and direction of the service. Records confirmed people, their relatives and staff were given an opportunity to be involved, give suggestions and feedback. Staff were complimentary about the providers mission which was, ‘People, Passion, Purpose.’ Many staff had demonstrated loyalty and appreciation of the vision, as they had committed long service to Maiden Castle House.

The service 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.

People and staff benefitted from strong leadership of the service. The registered manager was passionate about the care and working conditions of Maiden Castle House, and told us, “I am obsessed with being the best.” Procedures within the service were in place to ensure there was management presence and visibility within the service. People and their relatives knew who the registered manager was and told us they were accessible to them whenever they needed. The registered manager told us they were supported by the provider and by their management team within the service. We received positive feedback about the management of the service, some of the comments were: “I have every faith in the registered manager. I have a lot of respect for them”, “The registered manager is down to earth, and will try and help anyone”, “The deputy manager is straightforward, they are lovely”, “The registered manager is approachable”, “The registered manager and deputy manager are really helpful and have an open door.”

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

Staff knew how to raise concerns and ‘speak up.’ There were various ways available to staff both within the service, for example through the provider, and to external agencies such as the local authority. Staff told us they were confident in the registered manager and management team to address any problems they had. They said the registered manager was visible and accessible. The provider had various systems in place to ensure voices could be heard and staff told us they appreciated the provider listening to them.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they felt accepted by their colleagues, and teamwork was strong within the service. Staff preferences and individual circumstances were considered and supported by the provider and the registered manager. The service was supported by the providers specialist team for human resources. A member of staff said, “My colleagues are good, we are a close-knit team.” Equality, diversity and inclusion were included throughout all policies and procedures in the service.

The service 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance and oversight were robust. Oversight systems were multi-layered, this included checks carried out on behalf of the provider. Comprehensive audits and checks were in place to identify areas for development. The registered manager had made all notifications to CQC as required by law. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. A health and social care professional said, “The registered manager is approachable, knowledgeable, and maintains good oversight of the home’s operations.” Audits and checks produced an overall service improvement plan; this had clear timescales and responsibilities. Reviews of improvement plans were ongoing and had the scrutiny of the registered manager and the provider. The service had several meetings which included daily, weekly and monthly reviews of the whole service. The management team at Maiden Castle House were a finalist in the providers internal recognition awards, the registered manager told us they were proud of the recognition. The providers comprehensive policies underpinned working practices within the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service shared information and worked with a wide range of professionals and services. We received positive feedback from external stakeholders and professionals who worked with the service. A health and social care professional told us, “The partnership is good. We have established a positive working relationship with the staff, who are consistently welcoming and cooperative.” People told us they felt part of their community. The service had access to a minibus to support people to visit local places of interest. The registered manager told us about future and previous plans and ideas for improving community involvement. The registered manager showed us previous community engagement, this included, providing hot meals, local scouts club singing happy birthday to a person, accessible cycling, pre-school visits and a motorbike club visit. There had also been animal therapy sessions for people. A person told us, “It was wonderful having the donkey’s visit. I really enjoyed this.” The registered manager told us about fundraising and donations the service and provider had made to local and national charities, for example, the service had donated to the local animal welfare charity. People had visited places to make and secure links to their community. The provider and staff had completed fundraising and welcome days and summer fairs. The service worked well with other services such as hosting networking and peer support meetings, as well as involvement in local care associations

The service 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. They actively contribute to safe, effective practice and research.

The registered manager told us about the ways in which together with the provider they were continually looking to develop the service. The provider had oversight of the service and undertook their own internal audits and checks to ensure safe operation. The registered manager was confident and worked well with their management team. They understood the importance of continual improvement within the service. The registered manager was assured their systems enabled them to have effective oversight and promoted continuous improvement.