Fallowfield

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.

The last rating for this key question was Requires Improvement. At this assessment we found improvements had been made and the rating has now improved to Good. This meant people received a service that was well led.

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 service and staff were welcoming, and staff spoke positively about the leadership at the service. There was a positive and inclusive culture, and people and their relatives spoke positively about the service and felt it was a good place. There were clear values in place and staff were aware of these. Staff spoke positively about the registered manager. A staff member commented, “Managers listen and are approachable. I feel supported, and there is good teamwork. It is easy to speak up about concerns at any time and there is a good culture in the home. The staff team is diverse, and we all have different backgrounds and experiences.”

The registered manager was receptive, open to feedback and transparent. There was a clear emphasis on continued development and improvement within the service which was supported by enthusiastic staff. The registered manager led by example and had an open-door policy. Information was communicated and shared effectively with staff through daily meetings, supervisions and regular staff meetings. Meetings held showed opportunities for all to comment and provide meaningful input, helping to drive service improvements.

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.

Since our last assessment of the service, there had been changes to the management at the service. There was a new registered manager in post who had worked for the provider for many years and was familiar with the provider’s policies and procedures. The registered manager was knowledgeable about their responsibilities regarding the Health and Social Care Act 2014. They were aware of the types of significant events which they were required to notify CQC about and records showed the service had submitted notifications to CQC where required.

People and their relatives spoke positively about the registered manager. Comments included, “She comes and sees us every day, always helpful”, “She is very helpful and pleasant”, “A marvellous person”, and “She always pops in to say hallo and is very helpful.”

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

Management were visible within the service and people and staff we spoke with told us they felt comfortable going to the registered manager if they had an issue or concern. There were systems to enable staff to speak up. Staff told us they attended regular staff meetings and daily handover meetings where they were able to have a voice.

A whistleblowing policy was in place; this included the principles of freedom to speak up. Staff told us they were aware of the whistleblowing policy and felt they would be supported if they raised any concerns. Information about how to raise concerns was clearly displayed within the service in accessible formats.

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 supported staff to feel included and treated them with equity, taking account of their individual needs. There were policies and procedures in place to ensure staff were well treated and did not face discrimination. These included procedures during recruitment and throughout employment. Staff undertook a range of training to understand about equality and diversity.

The service operated an employee of the month programme where staff were rewarded for their hard work.

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 registered manager was supported by the provider and regional director and were able to regularly discuss the management of the service. The registered manager told us the regional director offered frequent support, and they worked well together to ensure good management of the service. The registered manager had a clear presence within the service, and we observed them speaking with people, relatives and staff regularly throughout our assessment. They worked alongside staff and observed staff practice to identify any areas which could be improved upon.

There were robust systems in place for monitoring and improving the quality of the service. These included audits and checks to monitor and ensure people received safe care and treatment. The registered manager completed a range of audits, checks and observations which covered areas such as call bell monitoring, safeguarding, accident and incidents, care plans and records, staffing, complaints and the home environment. Upon review, we saw that where issues had been identified, actions had been taken, and managers monitored the progress of improvements and practice to ensure they were fully embedded.

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. Leaders built good relationships with external health and social care professionals to make sure people received the right care at the right time.

The service worked well with health and social care professionals to meet people’s needs. This included visiting GP’s, pharmacist, speech and language therapists, dieticians and local hospices.

The registered manager worked with organisations and local services to further develop staff training to ensure staff had the knowledge and skills to undertake their roles. This included a local hospice, for best practice end-of-life care. The registered manager worked closely with the local authority’s commissioning team and attended their care home forums which provided them with opportunities to share best practice.

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 and effective practice and research.

The registered manager had a positive approach to learning and developing the service and staff. There were effective systems in place for learning and to share lessons learnt and best practice. The registered manager showed us that they recognised the importance of learning lessons and how they implemented systems within the service to ensure people received safe and effective care and support.