Gracefield Health Care Limited (GHC) - 31 St Domingo Grove

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. The service was in breach of the legal regulation in relation to good governance and the provider had failed to implement effective systems to improve the quality and safety of the service

At this assessment the rating has changed to good. There had been enough improvements, and the provider was no longer in breach of the regulations

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 based on transparency, equity, equality, human rights, diversity and inclusion, engagement, and an understanding of the needs of people and their communities. Although the provider acknowledged there had previously been a negative culture within the service, staff and the registered manager told us this had improved significantly over time. One staff member described the service as, “We are all a little family.”

The service had a clear statement of purpose and service user guides, which helped ensure everyone understood the aims, values, and expectations of the service. Staff attended regular team meetings where information was shared, and important issues were discussed, helping to maintain a consistent and shared approach to people’s care and support.

A structured induction process was in place, so new staff were well prepared and understood the culture and standards expected within the service. This included time for new staff to read everyone’s care plan. Ongoing training was provided through face to face sessions, specialist courses, and eLearning to ensure staff had the skills and knowledge to meet people’s needs.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. Leaders embodied the organisation’s values and culture, acting as positive role models for the workforce. They had the skills, knowledge, experience and credibility to lead effectively, and demonstrated integrity, openness and honesty in their approach.

Staff told us they felt well supported by the management team and described leaders as approachable and responsive. One staff member told us they felt “Really valued, we are all really looked after.” One staff member shared with us, “Management support has recently improved. Happy with the support I get.” Another staff member commented, “Feel very supported by managers. We work with a good team.” Relatives also told us they had confidence in the leadership team and the direction the service was taking.

The employment of a compliance lead had helped move the service forward by strengthening oversight, improving consistency and ensuring issues were identified and addressed promptly. Staff and relatives echoed that this role had brought clearer structure, accountability and focus to improving the quality of care, and had contributed to the positive culture now evident within the service. One relative told us, “[compliance lead] is amazing, they really communicate with us."

The provider fostered a positive and open culture where staff felt able to speak up and were confident that their concerns would be taken seriously. Staff told us they knew how to report any worries and could raise issues directly with the compliance lead or the registered manager. They were also aware of their right to contact the CQC if needed. One staff member explained, “I would contact [the compliance lead] or the manager, or I can contact Care Quality Commission if I need to.”

One staff member reported they felt listened to and concerns would be actioned, they stated, “I feel able to raise any concerns, and feel listened to."

The provider valued having a diverse workforce and promoted an inclusive and fair culture where staff from all backgrounds felt respected. Staff were supported in a range of ways to help them succeed, including through reasonable adjustments and additional guidance where required.

Everyone had their own role and responsibilities within the service, which helped staff feel valued for their individual strengths. When staff experienced racism or discriminatory behaviour from people living in the service, leaders acted quickly to support them and manage the situation safely. This helped create a workplace where staff felt protected, listened to and confident to raise any concerns.

The provider had clear responsibilities, defined roles, and effective systems of accountability and governance to support the delivery of good quality, safe and sustainable care. Leaders acted on reliable information about risk, performance and outcomes, and shared relevant information securely with others when appropriate. A robust governance framework was in place, with clear lines of responsibility and strong communication between internal teams and external professionals to drive continuous improvement. Positive relationships with specialist services also fed into how the service was managed, helping ensure risks were identified, assessed and managed appropriately. The management team were aware of each person’s needs, which strengthened oversight and helped them respond promptly to changes in people’s care. One professional spoke highly of the management team, they shared, “I was always particularly impressed with how well led the service was, the management were very responsive, they knew the people who live there well and regularly spent time with them. It was always a lovely place to visit.”

However, although these systems were detailed, they were not always fully effective. We identified that auditing tools did not always correlate; for example, one person was recorded as having 2 incidents in a month, while another audit tool showed 3. This discrepancy was fed back to the management team, who acknowledged they were aware of the issue and as a result had produced a new team audit form. This was designed to provide more in-depth reporting and recording processes, reducing the risk of human error and improving the accuracy of oversight.

The provider understood their duty to collaborate and work in partnership so that services operated seamlessly for people. They shared information and learning with partner organisations and collaborated with them to support ongoing improvement. There was clear evidence of effective multi‑agency working, with established protocols and joint initiatives that promoted coordinated care and improved outcomes for people. The provider actively shared relevant information in a timely manner, supporting transparency and consistency across services. The service worked closely with other agencies to achieve the best possible outcomes for the people they supported. Staff told us they knew who to contact when specialist advice was required, and they had developed strong working relationships with a wide range of health and social care professionals with specific expertise.

The provider focused on continuous learning, innovation and improvement across the organisation and within the local system. They encouraged creative and effective ways of delivering equitable experiences, outcomes and quality of life for people. The service actively contributed to safe and effective practice and remained engaged with current guidance and developments.

Staff received training relevant to their roles and areas of specialism. For example, the housekeeping team attended external infection prevention and control (IPC) meetings 4 times a year to share information and ensure their knowledge remained up to date. Staff also received service specific training to meet the individual needs of people living in the service supporting consistent and informed care.