Downham Grange

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 inadequate. At this assessment the rating has changed to requires improvement. Although there had been some improvement within the service; the management and leadership were inconsistent.

Leaders and the culture they created did not always support the delivery of high-quality, person- centred care. The service was in breach of the legal regulation in relation to good governance.

This service scored 61 (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, and culture. This was based on equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Although the service did not discuss their shared visions with the workforce, the service did hold staff meetings frequently and the service had a clear mission’s statement for staff to follow which recorded their values. Speaking to staff they did not know what they were but knew where they could access them. Staff felt there was a good culture within the service.

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. Staff spoke positively about the service and felt the leaders were approachable throughout the whole organisation especially the registered manager. 1 person told us “Manager is always helping on the floor when needed, yeah, I think they respond appropriately. Anytime I had an issue I know I could approach them and discuss it.” We reviewed records that showed incidents were handled with honesty and integrity.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt they could raise concerns and when they had, they had been taken seriously, and appropriate action has been taken while incidents were investigated. The service carried out surveys for the workforce and once completed; actions were developed from them fed back to the team. The staff have a whistleblowing policy in place and could explain what was meant in freedom to speak up. 1 staff member said “there would be no comeback on an individual speaking up. It's not acceptable to keep quiet about things, we have to speak about them, address them and resolve them. We all have the right to work in a safe environment.”

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 service had clear policies and procedures around equality, diversity and inclusion for staff to follow, people were entitled to flexible working arrangements. All the staff we spoke with raised no concerns.

The provider did not have clear, systems of accountability embedded and good governance in place. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. We identified several shortfalls in the quality management, systems and reporting. Care plan audits failed to identify inconsistencies and errors recorded in care records which made them unclear for staff to follow and they were not a true reflection of the care a person received, this included safety checks, assessing incidents, risk assessing and peoples care and support needs. They failed to ensure concerns regarding people's health concerns were shared with the appropriate healthcare professional. Action plans from other stakeholders were signed off as complete, on review of these actions they were still outstanding and had not been identified through internal audits. Although we were sent a dependency tool after the inspection, we were not assured the services dependency tool was being actively used within the service. The provider failed to identify the concerns we found with the gaps in training for staff and the recruitment checks. The governance was ineffective and failed to identify these concerns to ensure systems and processes were being embedded within the service.

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. Most people we spoke with explained how the service involves the community and could give examples of different activities that were carried out. Healthcare professionals told us “The leadership and staff at Downham Grange care home are consistently professional and open to feedback and we have no concerns regarding the quality of care” The service ask for feedback from partners on how they can improve the service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. We were not assured that all actions we accurately implemented and embedded within the service. We identified actions that posed a risk to people had been signed off as complete within their records, although this was not a true reflection and risks were still identified. However, the service was proactive in resolving this issue and offered assurances on how they would achieve this. Speaking to staff they could evidence other ways that the service had implemented actions to improve people’s quality of life.