Coldwells 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 outstanding. At this assessment the rating has remained outstanding.This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 had a clearly-established purpose and core values, and leaders encouraged staff to work to the standards they had set. Staff told us there was a strong culture of collaboration among the team. A staff member told us, “We have good atmosphere, we have a good team, it helps a lot.” Managers ensured the culture of the service was person-centred, empowering and inclusive; and developed through collaboration with others. The provider invested in staff. Staff were well supported, could access extra training and development opportunities and progressed in their careers when opportunities arose.

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.

Feedback relating to the management team was positive. A person told us, “They the best reputation in the area”.

There were systems and processes in place to support staff development. Staff talked of how they were supported to attend training or given informal training and support on the job from experienced staff. Staff supervisions and competency checks took place.

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

Staff we spoke with were confident their voices were heard, and action would be taken. Staff understood how to speak up and the process for doing so. There was a culture of speaking up where staff were able to raise concerns without fear of detriment. The management team had an ‘open door policy’ which meant people, staff and families could approach them at any time if they had any concerns. The service had policies and procedures that supported staff in speaking up. Policies included the topics of safeguarding and whistleblowing. The registered manager told us the service actively supported staff to speak up with any concerns.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them.

Staff told us they were treated equally regardless of their gender, nationality or health conditions. A member of staff told us about their specific health condition and how they were anxious this could affect them at work, and how staff would respond if they became unwell. The provider introduced emergency protocol with the staff’s consent specific to their health condition with clear guidance including signs to look out for and step by step guidance when to use specific medication and when to call 999. The member of staff told us, “Because of this support and the measures put in place, I feel confident continuing to work following my diagnosis. I know that I’m not alone and that there is a clear plan in place to keep me safe while allowing me to continue my role.”

The service promoted inclusion and celebrated diversity. Staff and people using the service had open discussions about LGBTQ+ topics to help develop their knowledge and understanding. People and staff felt supported and included regardless of their background.

Staff spoke positively about how the service supported equality, diversity and inclusion. For example, a staff member praised the support they received from leaders during personal circumstances. The staff member told us they would not be able to work for the service if they had not received this support.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

This was the second inspection where the service produced multiple examples of going above and beyond to monitor and improve the safety and quality of people’s care. The provider had a detailed and robust governance framework in place. Audits, reviews and service monitoring tools were completed monthly, and key performance indicators were reviewed and analysed by the registered manager and the management team. The outcomes from the monitoring and reviews supported the management team to manage quality and inform continuous service improvement and development. The provider implemented recognised standards and best practice, by ensuring policies were regularly updated, and the business continuity plan detailed their preparedness for emergencies and adverse events.

A healthcare professional told us, “The care provided is attentive, personalised, and compassionate. The atmosphere in the home is warm and friendly, and the environment is consistently clean, tidy, and nurturing. When I walk around the home with the deputy manager, it is evident how genuinely caring the staff are – the residents are pleased to see them, and the interactions feel kind, respectful, and heartfelt.”

We were assured people received their care from a service that continually monitored standards and constantly looked at how improvements could be made. The governance and improvement agenda were firmly embedded into all areas to improve service provision.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.

The service has developed outstanding relationship with other healthcare professionals that had positive impact on people’s lives. A healthcare professional told us, “The staff know each resident deeply and as an individual. Every effort is made to understand and meet their personal needs, preferences, and any specific requirements. Because the staff know the residents so well, they are quick to recognise when someone is unwell or when something isn’t quite right. During my regular visits, when we review residents together, it is clear that the team has an excellent grasp of each person’s baseline health, personality, and behaviours. This gives me great confidence that any change or concern will be identified promptly and escalated appropriately.”

Another healthcare professional told us, “The care provided has always appeared to be of a high standard. They have a good knowledge of all their residents and raise concerns with the appropriate healthcare professional in a timely manner. They advocate for their residents well.”

The service developed links based on compassion and caring with a local hospice. For example, a person was supported to be with their spouse during the final stages of their loved ones life at a local hospice and was able to attend all required health appointments despite being unable to access these independently.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 service demonstrated an outstanding commitment to learning, continuous improvement, and innovation, ensuring people, families, and staff benefited from a dynamic and forward-thinking environment. They introduced such innovation as acoustic monitoring system which did not only improve people’s quality of sleep but also helped to detect respiratory issues and prevent chest infections.

People were encouraged to use assistive technology to encourage good communication and promote independence.

The provider demonstrated a commitment to evidence-based dementia care by integrating recognised best practices into both the physical environment and daily routines. By employing therapeutic modalities such as doll and pet therapy, the service addressed the emotional and psychological needs of people. Furthermore, the provider utilised people’s life histories to ensure that care plans were deeply rooted in each individual’s past experiences, complemented by a specialist dementia-friendly environment designed to reduce agitation and promote independence.

Accidents, incidents and near misses were reported, investigated and changes made to reduce the risk of them happening again. Staff were kept informed of lessons learned through daily meetings held by the management team.

It was evident throughout inspection there was a strong emphasis on people’s quality of life and how this could be improved.