Downs 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 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.

The service was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this 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.

Visiting professionals provided positive feedback about the culture and values of within the service. On professional said, “It is wonderful here, we have been coming a long time and it’s one of the best parts of our job coming here”. The provider said, “I am here a lot to support the home whilst we recruit into various posts. I can see the culture is good”.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Some leaders were new in their role and not all members of the leadership team were fully familiar with the provider’s systems and processes, which at times, resulted in communication challenges. They required time to understand the governance arrangements, become familiar with the provider’s framework, and build relationships with staff and the people they supported. A staff member commented, “Sometimes we are not sure who is meant to be doing what.” Despite this, the leadership team demonstrated commitment to embedding improvements and strengthening oversight, ensuring that progress continued in line with regulatory requirements. They did so with integrity, openness and honesty.

The management team encouraged reflective practice and supported the professional development of their staff, fostering a compassionate and skilled workforce. A member of staff said, “I am getting used to things now but feel we will be in a better position when everyone is more settled”.

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

A culture of openness was encouraged. Staff felt confident raising concerns, raising safeguarding issues, or suggesting improvements without fear of reprisal. The home had clear mechanisms for reporting and responding to concerns.

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 home promoted diversity and inclusion within its workforce. Policies supported equality, fair treatment, and reasonable adjustments for staff from all backgrounds. This inclusive culture helped staff deliver personalised care with respect and understanding.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance arrangements were in place, including risk registers and quality monitoring. The provider was open and said, “There are some areas we can be better on but we are aware of this and we have plans in place”. The provider had strong foundation for improvement. Defined accountability was in the process of being clarified and strengthened to ensure consistency across the service.

Leadership actively used data from incident reports and audits to drive positive change. We saw evidence of progress in several areas including in the management of meetings, one to one supervision structures, medication procedures and infection control. Some managers and staff were new to the service and required time to familiarise themselves with the provider’s governance and auditing processes. However, they demonstrated commitment to learning and implementing best practice, supported by clear oversight and guidance from the provider.

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 home worked collaboratively with external partners: health services, social care agencies, and local stakeholders. Learning was shared and co‑ordinated, which allowed the home to improve practices and contribute positively to the wider community.

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 organisation had a continuous improvement approach. Managers encouraged innovation through staff feedback, audits, and reflective debriefs. Changes were made based on learning from incidents, feedback, and best‑practice research. The providers action plan developed following our previous inspection was effective in driving improvements and ensuring the service met the legal requirements.