Somerset 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 good. At this assessment the rating has remained 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.

Staff demonstrated a shared commitment to providing high quality, person centred care and were able to describe the provider’s values and explain how these influenced their day to day practice. This helped to promote a positive culture where people were treated with respect, kindness and fairness.

People’s individual backgrounds, beliefs, identities and life experiences were recognised and respected. Care was delivered in a way which valued each person as an individual, and reasonable adjustments were made to reduce barriers and promote equitable access to care and support.

There was an open and transparent culture within the home. Staff felt confident to raise concerns, share ideas and contribute to the ongoing development of the service. The provider encouraged honest communication and learning, and staff told us they felt listened to and supported; this helped foster trust and accountability across the service.

The provider actively engaged with people, relatives and staff to understand their experiences and views. Feedback was welcomed and used to inform decisions and improvements. The provider demonstrated awareness of the challenges faced by people, and the wider local community, and used this understanding to adapt and develop care delivery.

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.

Leaders consistently embodied the culture and values of the organisation and promoted a compassionate, inclusive and respectful approach to care, which was reflected in staff attitudes and behaviours. The most recent residents survey indicated staff treated people with dignity and respect and were pleasant and courteous.

Leaders demonstrated the skills, knowledge and experience required to lead the service effectively; they had a good understanding of best practice, regulatory requirements and the specific needs of a small care home environment. This credibility helped staff to feel confident in leadership decisions and supported a stable and well run service.

Leaders communicated clearly with staff, people and relatives, and were approachable and visible within the home. Staff told us they felt able to raise concerns, ask for guidance or share ideas without fear of negative consequences. Leaders responded constructively and fostered a culture of learning and improvement.

Compassion was evident in the way leaders supported both people and staff. Leaders recognised the emotional and practical challenges involved in providing care and took steps to ensure staff felt valued and supported. This helped staff deliver care with empathy, kindness and professionalism. The registered manager had been in post for many years, creating stability and consistency within the home.

Leaders promoted inclusion and equality; they were mindful of diversity and human rights and ensured these principles were embedded into policies, practice and everyday decision making. Reasonable adjustments were considered where needed, and leaders demonstrated respect for individual differences, among both people and staff.

Leaders operated with integrity, openness and honesty, and effectively guided the service in a way which supported high quality care, positive staff morale and good outcomes for people.

Staff were able to describe the values of the service and explained how leaders role modelled these in their day to day interactions, reinforcing a positive and supportive culture. A staff member told us, “Team leaders in the home are skilled in solving problems that may arise and they provide the correct support to staff and people equally and respectfully, without being biased, and offer care and compassion to all. I believe they have 100% effective knowledge and skills to lead the team correctly.”

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

People, relatives and staff were encouraged to share their views, raise concerns and express worries without fear of being ignored or treated unfairly. People told us they felt comfortable speaking openly with staff and leaders about their care and support; they said staff were approachable and listened respectfully, taking time to understand what mattered to them.

People felt reassured any concerns would be taken seriously and acted upon. The provider promoted transparency and openness within the home. Information about how to raise concerns or complaints was accessible, and staff explained this clearly to people and relatives. People knew who to talk to and felt confident their concerns would be handled fairly and sensitively.
Staff described a culture where speaking up was actively encouraged. They told us leaders were open, supportive and responsive, and they felt safe to raise issues, ask questions or share ideas. Leaders responded constructively, focusing on learning and improvement.

Where people or staff raised issues, these were addressed promptly and outcomes were communicated clearly; this helped build trust and showed speaking up made a difference. Our analysis of the most recent survey results showed people were consistently pleased with the quality of care provided and how they were treated by staff members.

Leaders were visible and approachable, regularly engaging with people, relatives and staff which helped to reinforce an open culture and made it easier for people to raise worries informally before issues escalated. Good communication was in place through team meetings, daily meetings and formal individual supervision sessions to ensure staff had regular opportunities to engage with leaders. This was also supported by policies and information supporting staff, or people and relatives to raise concerns externally if required.

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.

Leaders provided flexible working agreements to staff to account for personal circumstances such as caring responsibilities and health issues and had put reasonable adjustments in place for some staff to help them carry out their role. A staff member said, “Certain staff can only work certain hours, so the service ensures they have shifts which are flexible for them.”

Leaders took steps to ensure staff were representative of the population of people being supported. Staff told us they were treated equally by leaders. A staff member told us, “I believe I am treated fairly well, as are the other staff members. Staff can take breaks to rest or have meals and drinks to stay dehydrated.”

Managers engaged with staff via appropriate forums such as individual supervisions, various staff meeting types and staff surveys, to ensure their voices were heard. Staff were confident they could raise concerns directly with their leaders, and had received training in equality, diversity and human rights. This was also supported by policies and information supporting staff, or people and relatives to raise concerns externally if required.

The most recent staff survey indicated good teamwork, and a sense of team camaraderie.

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 provider had effective governance, management and sustainability arrangements in place. Clear leadership, good oversight and the use of performance and risk information supported the delivery of high‑quality, safe care. The provider had clear responsibilities, defined roles and effective systems of accountability and governance; these arrangements supported the delivery of sustainable care.

The provider and registered manager understood their roles and responsibilities and worked closely together to oversee service delivery. Reporting lines were clear, and staff knew who to approach with concerns, questions or ideas for improvement.

There were effective systems in place to monitor the quality and safety of the service. Governance meetings and management oversight ensured care quality, staffing, health and safety, and regulatory compliance were routinely reviewed. Where actions were identified, these were recorded, assigned and followed up to completion. The provider used a range of quality assurance processes to monitor performance and outcomes. These included audits of care records, medicines management, safeguarding, infection prevention and control, and the environment. Findings from audits were analysed to identify risks, trends and areas for improvement.

Feedback from people, relatives and staff was actively sought and valued; this information was used alongside audit findings to inform service improvements and maintain good standards of care. Risks to people’s health, safety and wellbeing were identified and managed effectively. Individual risk assessments were in place and reviewed regularly to reflect people’s changing needs. Wider service‑level risks, such as staffing and environmental risks, were also monitored through governance systems.

The provider acted on the best available information about risk and performance. Incidents and near misses were reviewed to reduce the likelihood of recurrence, and learning was shared with staff to support safer practice. A business continuity plan was in place detailing emergency preparedness and what should happen in different situations such as fire or flood. Statutory and regulatory notifications were sent to CQC as required.

Records were accurate, up to date and securely stored in line with data protection requirements. The provider had systems in place to ensure people’s information was handled confidentially.
Where appropriate, relevant information was shared securely with health and social care professionals, commissioners and external agencies to support continuity of care and positive outcomes for people.

Leadership was stable and supportive. The provider ensured there were enough suitably skilled and experienced staff to meet people’s needs. Workforce planning, recruitment and training arrangements supported the ongoing sustainability of the service.

Leaders promoted a positive, open culture where staff felt listened to and supported. There was a clear commitment to continuous improvement, and the service was responsive to changes in guidance, legislation and best practice.

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 provider worked constructively with a range of external partners, including GPs, community nursing teams, social workers, and other health and social care professionals. These partnerships helped ensure people received timely, coordinated support to meet their health and wellbeing needs.

Staff knew how and when to involve external professionals. Communication with partners was clear and focused on people’s individual needs. Staff maintained positive links with the local community, helping people to remain connected and supported; this included engagement with local services and community resources where appropriate, supporting people’s social wellbeing and sense of belonging.

The provider shared relevant information securely and in line with data protection requirements. Care information, risk assessments and updates about people’s needs were shared with partners when appropriate to support safe and effective care planning. Information received from other professionals was acted upon promptly and incorporated into people’s care plans to ensure care remained consistent and responsive to people’s changing needs.

The provider demonstrated a commitment to learning and improvement through partnership working. Feedback, guidance and recommendations from external professionals were welcomed and used to improve practice within the home. Where issues or risks were identified, leaders worked collaboratively with partners to find solutions and improve outcomes. Learning from incidents, reviews or external advice was shared with staff to strengthen practice and prevent reoccurrence. Leaders understood the importance of the home being an active part of both the wider care system and local community, rather than working in isolation.

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 encouraged reflective practice and used learning to improve equality of experience, outcomes and quality of life for people. Learning opportunities were embedded into everyday practice through staff supervisions, team meetings, training and reflective discussions. Staff were encouraged to learn from incidents, feedback, audits and external advice to improve care delivery.

Leaders used learning from complaints, incidents, safeguarding concerns and compliments to drive improvement. Where changes to practice were required, these were implemented and monitored to ensure they were effective and sustained.

Care was tailored to meet people’s individual needs, preferences and backgrounds, helping to promote equality of experience and positive outcomes for all people. Staff were supported to suggest new ways of working and improvements to care routines, focussing on practical improvements, such as adapting activities, communication methods or daily routines, to better support people’s independence, dignity and wellbeing.

The provider demonstrated a commitment to promoting equality and ensuring people received equitable care and support. Learning from individual experiences was used to shape care planning and improve outcomes. Staff showed awareness of people’s individual circumstances and worked creatively to reduce barriers to participation and inclusion; this helped ensure people experienced a good quality of life and felt respected and supported.

The provider welcomed guidance, best practice recommendations and learning from health and social care professionals and used this to improve care delivery. Where appropriate, the service contributed to discussions and reviews focused on improving safety and effectiveness, such as multidisciplinary reviews or shared learning initiatives; this collaborative approach helped strengthen practice within the home and supported safer outcomes for people.

Leaders promoted a positive culture of openness, learning and improvement. Staff felt supported to reflect on practice, raise concerns and contribute ideas for improvement without fear of blame. Continuous improvement was seen as a shared responsibility across the team.

The provider demonstrated responsiveness to change, keeping up to date with guidance, standards and emerging best practice to ensure care remained effective and person centred. The registered manager told us, “We have a service improvement plan and there is investment allocated to this. The directors are committed to constantly striving to improve. Somerset House has recently undergone a complete refurbishment. We invest in the development of our staff and in doing so, this will result in better practice and outcomes. We also review whether our current systems are working and whether there is anything that can be done to improve.”