Abbeygate

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. At the last assessment, we found governance was not always effective. At this inspection we found improvements had been made and the provider was no longer in breach of regulation.

This service scored 68 (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. People told us they felt safe and comfortable living at the service. Staff and leaders were dedicated to both the service and the people they supported. The provider respected people’s human rights and embraced diversity across the organisation. Communication between managers, staff, and people using the service was open and transparent. During our site visit, we observed a caring and supportive environment. Staff reported positive morale within the team and spoke well of their managers and roles. One staff member shared, “We’ve got a lovely team.”

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. The service had an established registered manager in post who demonstrated their experience and understanding of the service. Leaders were visible, engaged, and actively contributed to the assessment process. Staff told us they felt well supported by the management team. Throughout the assessment, the management team demonstrated openness and transparency. They responded proactively to our findings and took prompt action to address shortfalls identified. A professional said, “Very well managed by the manager.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The registered manager shared an example of responding to a concern raised by staff, which was appropriately investigated and referred to the local authority safeguarding team. The provider had processes to support staff to speak up, including team meetings and supervision sessions. The provider had procedures to support staff in raising concerns and contacting external agencies when needed. Staff told us they felt supported and able to raise concerns with the management team. One staff member said, “[Registered manager] has an ear for everyone.” Another commented, “Yes, registered manager would take action.”

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. The provider explained how they supported the diverse needs of their staff team. For example, staff members with learning needs received additional support and adjustments. Although the service was founded on a Christian ethos, the management team told us they respected the varied religious and cultural beliefs of all staff. Staff had access to equality training to support their understanding of protected characteristics and raise awareness of bullying and harassment. Staff told us the registered manager was approachable and responded appropriately. One staff member commented, “[Registered manager] has always said, come to me with any concerns.”

The provider did not always have systems of good governance. They did not always act on the best information about risk, performance and outcomes. The provider was completing regular service level and provider level audits to monitor the quality and safety of the service. Since the last assessment, governance had improved. For example, governance processes had led to improvements in the service environment, risk assessments, staff training and policies and procedures. However, some audits required further development to be fully robust, identify areas for improvement promptly and monitor progress. For example, while improvements had been made, audits of risk assessments and staff training required further work to ensure they were consistently effective. The management team was well established, and the service had clear governance, management and accountability arrangements. Where audits had identified areas for improvement, we saw evidence these were added to action plans to be addressed. The provider had processes to inform relevant partners when incidents or safeguarding concerns occurred. The registered manager submitted information to the CQC as required. The management team responded positively during the assessment, providing evidence of actions taken to address the shortfalls identified.

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 told us how they worked in partnership with professionals such as the GP and district nurse to meet people’s individual needs. The management team told us they participated in provider forums to exchange ideas and share best practice related to service delivery. Professionals told us there was good communication with the service. A professional said, “The manager always seeks support when needed and has been to a number of events that promote care home work.”

The provider had not always focused on continuous learning, innovation and improvement in the service. At the last assessment, some individual and environmental risks were not sufficiently assessed and mitigated, governance systems were not always effective. At this assessment, while some improvements had been made further work was needed to embed improvements and establish a consistent culture of learning, innovation and improvement. We identified additional areas where risk assessments needed to improve, and staff training which had not been completed. The provider had processes to involve people, their relatives, and staff, and to gather feedback through meetings and surveys. The provider had systems to support learning when things went wrong. Staff reported having opportunities to share feedback and ideas with the management team, both informally and through meetings. The management team was committed to providing a quality service and responded promptly to shortfalls identified during the assessment.