Grosvenor 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.

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.

There was a positive culture at the service. One staff member told us, “We’re a good team, staff are updated and we know what is going on.” Another staff member said, “We’re well supported, we can speak to [registered manager] and we’re listened to.” The registered manager and staff team were committed to improving and developing the service.

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.

People and relatives knew the management team and spoke highly of them. One person spoke about the registered manager and said, “I see her on and off. She is always available if I want to go and see her, which I do now and again.” Another person told us about the deputy manager, they said, “She has a skill of getting everyone to do things around here.” One relative said, “[Registered manager], is very warm and thoughtful.” Another relative told us, “She is accessible during the week usually in her office. When I go in, I can have a chat with her, and she is always keen to talk.”

There was a clear management structure at the home. The registered manager was supported by a deputy manager and senior care staff. Senior care staff were responsible for the smooth running of each shift. Before staff took on additional roles the registered manager ensured they had the knowledge, skills, competence and confidence to do so. We saw the registered manager was supporting staff to develop their knowledge and skills and identifying areas where staff required more development. They also ensured there were enough staff with relevant skills to manage the service in the absence of others. Staff told us there was an open-door policy and there was always someone they could talk to.

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

Staff understood the whistle-blowing policy, and this was displayed in the staff office. Staff told us they would report any concerns to the management team, or if this was not appropriate, they would contact head office. One staff member told us that although they were not sure of what to do, they knew where the policy was and they would follow this. Staff were confident that issues raised would be addressed.

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 received training in equality and diversity. They were encouraged to share concerns and ideas through supervisions and team meetings. Staff told us they felt valued and everyone worked well together. Staff said their individual needs and culture were respected, and they gave us examples of this.

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 had good oversight of the service and risk, including the quality of people’s care and support. Supported by senior staff they completed daily, weekly and monthly quality and compliance checks. This included the auditing of the environment, medicines management, care and safety checks including environmental checks. The providers computerised system meant the provider also had oversight of the service based on information submitted by the registered manager. Regular audits were completed by the provider’s compliance manager. Where any shortfalls, or areas for improvement were required then an action plan was developed and demonstrated when these had been addressed.

The registered manager told us that where the computerised system did not provide the information they required, they would implement paper documents, so the information was not overlooked. During the inspection the registered manager showed us this for oversight of people’s weights. Following the inspection visits the registered manager updated us to say, following discussion with a senior manager they had been able to identify where the information was available on the electronic system. The registered manager told us this had shown them they were not using the system to its full potential and had booked onto further training. This would assist them to continual improvement of the quality of care and support provided.

The provider was aware of their statutory responsibilities to notify CQC about certain changes, events and incidents that affected their service or the people who use it. These notifications were submitted appropriately.

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 registered manager and staff team had developed positive working relationships with services who supported people living at the home. This was demonstrated through the records we saw. Staff told us how they would contact relevant external professionals to help them meet people’s changing and ongoing needs.

The management and staff worked with other organisations to support the local community. Grosvenor House was established as a local ‘Dementia Haven’ for people with dementia. This meant if anyone had concerns about their loved one, or local organisations were aware of people struggling with dementia they could go to the home. They would be made safe and arrangements would be made to ensure ongoing safe care and support. The registered manager gave us an example of when this had worked successfully. The registered manager and staff worked with local organisations and had provided a Christmas lunch for the homeless and socially isolated.

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 provider had systems in place to learn from accidents, incidents, safeguarding’s, survey results, complaints or when things went wrong. Action plans were developed and showed when shortfalls had been addressed. Issues were also discussed in staff meetings and supervisions.

Accidents and incidents were recorded; the registered manager and staff were able to tell us what actions had been taken to prevent a recurrence and information was recorded in people’s care records. However, the providers accident and incident record was not always fully completed to demonstrate actions taken to prevent a reoccurrence or lessons learned. We discussed this with the registered manager and discussed the need to ensure records are fully completed and contemporaneous.