The Belmont

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 71 (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. Staff spoke positively about the support they received from the registered and deputy manager. The provider’s aims and objectives for the service were set out in the Statement of Purpose. A Statement of Purpose is a legal document which outlines details of the service. In addition, there were a set of values which were displayed and discussed regularly at staff meetings. There was a culture of learning and development. We saw evidence of lessons learned being shared at discussed at meetings. The registered manager told us they were proud to manage the service and the positive relationship between staff and people and described it the service as a family.

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. Staff spoke positively about the management of the service. We found the management team approachable, capable and compassionate throughout our assessment. The manager was new in post from our last inspection; however, they had previously been the deputy manager at the service so knew staff, people and systems well. They told us they were supported by senior leaders to in their transition from deputy to registered manager. Staff spoke positively about the registered manager and deputy and found them to be supportive and approachable. The manager told us they operated an open-door policy for people, relatives and staff. Staff confirmed leaders were visible in the service and felt confident to approach them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of the providers’ whistleblowing policy and posters were appropriately displayed to remind staff how to raise concerns. Information was also available in the staff handbook which was issued to all staff upon commencing employment in the service.

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 provider promoted equal opportunities and had policies in place to ensure staff were treated equitably and their needs considered. They supported staff wellbeing by offering flexible working arrangements and accommodating time off for appointments and special occasions. The registered manager understood their responsibility to make reasonable adjustments for disabled staff. Staff completed equality and diversity training to support them to recognise and report discrimination and bullying. Staff were able to share their view through various channels such as meetings and surveys.

The provider had quality assurance systems in place to ensure regular check and audits were carried out on all areas of the service. However, we found these were not always effective and had not identified some of the concerns we identified during our assessment and detailed in the earlier sections of this report. The provider was receptive to our feedback and started taking action to address the concerns we raised. For example, providing additional training and increased observations. Shortfalls identified through the providers internal systems and external checks, including the findings from our assessment, were added to the Home Development Plan so actions taken could be monitored and reviewed. The registered manager informed CQC of notifiable events in a timely manner. Records of meetings and audits evidenced lessons learned when things had gone wrong.

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 leaders worked with the local community to enable people to feel part of the local community. People made regular visits to a local school where a book club had been established. Staff worked in partnership with a charitable trust to create an eco-memory garden. The local community were invited to attend a weekly memory café hosted by the service.

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. They actively contributed to safe, effective practice and research. The registered manager and regional manager told us they had regular meetings other managers from some of the providers other services. These meetings were used to share best practice and feedback from external inspections to learn and improve. Staff told us they were able to share ideas. Quality assurances systems were in place to enable the registered manager and senior leaders to have oversight of the service.