Speirs 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 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 staff team were encouraged to engage and share their experiences with the wider community. In 2024 the home had contributed to the provider receiving the ‘Investors in People’ award, which is the framework for assessing how an organisation develops their staff to achieve better performance. The registered manager told us they were involved in giving expert speeches to students from the local university and school about their career journey and experience of working in health and social care sector.

The registered manager felt well supported by the provider who always responded to the service's needs as necessary. The registered manager told us, "I don’t feel short of anything. Budget wise, I am not restricted to anything concerning the residents. I have opportunities to excel as a manager, I am not micromanaged."

The provider had inclusive leaders who understood the context in which they delivered care. Leaders had the skills, knowledge, experience and credibility to lead effectively. People and their family members, staff and healthcare professionals spoke well about the management of the service. People’s comments included, “[Name of the registered manager] doesn’t make a fuss, she is very good with the staff. As I said, she is sensible.” A staff member told us, “Oh, [name of the registered manager] is really nice, she is a good manager. We can approach her at any time. I don’t have any complaints.” A healthcare professional said, “I feel the service is overseen and managed well. The staff appear to be proactive with patient care.” There was a good management structure in place with shared responsibilities to ensure good care delivery. The registered manager was supported by a deputy manager to oversee the quality of the care being provided for people. The service had also planned to have more senior care staff for supporting the staff team to manage situations in an emergency.

The provider fostered a positive culture where people and staff felt they could speak up and their voice would be heard. Staff were confident issues would be dealt with by the management team as necessary. They said, “Yes, confident (to raise a concern). I can discuss with [name of the registered manager] first and then the head office. If not, we can always go to the CQC website or there is a place to whistleblow in Kingston. Definitely confident to whistleblow if needed.” The registered manager told us they had an open-door policy to ensure they addressed any issues staff had quickly and in good time.

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. A staff member told us, “The working environment here is very nice. You feel like it's a second home.” A registered manager said, “We take pride in supporting our staff to achieve their best and last year we supported 3 care staff with their professional development and graduating as nurses.”

The provider had clear responsibilities, roles and systems of accountability. 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. Effective governance systems were in place to monitor the care delivery. This included regular checks and audits being carried out by the management team in relation to call bells, complaints, medicines and incidents and accidents. Any delays completing the audits were showing up on the service’s electronic system which was monitored by the provider’s compliance team for assurance.

The service was in the process of transitioning their paper care records into an electronic records system. They thoroughly planned the migration to the new data base to ensure continuity of the care delivery, including an accurate uploading of information on the system and staff's robust training.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. The service worked well with the healthcare professionals and used their guidance to improve where necessary, including making changes to their safeguarding procedure so that the home could report any concerns raised effectively.

We received mixed responses in relation to the staff team’s interactions with the healthcare professionals. Some healthcare professionals described staff as ‘not the friendliest’ and ‘defensive’, whereas others said they were ‘approachable’ and ‘responsive’. The registered manager told us they didn’t’ have any negative feedback reported to them and if anything was brought to their attention, it would be addressed as a complaint in line with their complaint’s procedure. Nevertheless, the management team brought this issue to the staff team’s attention encouraging transparency and sharing of information in relation to their experiences of communicating with the healthcare professionals.

The provider focused on continuous learning, innovation and improvement across the organisation and service. People were involved in making suggestions for improving the service delivery. A person told us, “There are meetings. I asked about having fresh fruit on the menu. I was told that it was always available, I only had to ask. However, I said it should be actually on the menu because people don’t realise that it is available and won’t ask for it. They listened and now it is part of the menu.” Any actions arising were recorded in the ‘improvement plan’ which helped the service to monitor the progress being made and dates for completion.