Tikvah Woodpeckers

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. We reviewed the provider’s statement of purpose which clearly set out their values. We observed a culture of teamwork, and staff had time to engage with people and professionals. We observed the registered manager and staff working together to support people The provider had a welcome pack which clearly outlined what people can expect from them. The provider had a closed culture, professionalism and respectful practice briefing which outlined what a closed culture was and why it was harmful. This briefing provided informational links for staff to refer to for further support and guidance.

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. We observed the registered manager and staff supporting people in a person-centred way whilst demonstrating and understanding the needs of the people. A member of staff told us they were listened to by leaders when staff had concerns and they were provided with a 24 hour on call system. The registered manager told us the quality of care drove the service and they embraced the regulations, to meet the regulations to ensure tasks did not become task focussed. Relatives confirmed the registered manager led the service well. We were told, “Definitely, the fact that you have staff there for such long times, speak volumes. I’m sure a lot of other care homes could learn from them” and “[Registered manager] is very good.”

Relatives told us, “[Registered manager] is very approachable and [registered manager] will always respond clearly to any questions I raise” and, “The overall management of the service is good. They are very responsive to suggestions, and I am always kept informed.” A healthcare professional told us the registered manager led the service well and they did not have any concerns to report regarding the service. Another visiting professional told us when they visited the service, they felt part of the same team, and they had the same goal in providing the highest quality services to the residents and respecting they were in their home. We were told the registered manager was a very capable manager with a solid team of seniors that all worked well together.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistleblowing policy and procedure and held regular staff meetings. A member of staff told us staff were supported with regular team meetings and staff supervisions, and they could raise their concerns anytime. The provider completed regular staff surveys which included actions taken as a result of feedback received. For example, focussing on training.

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. Staff were supported through staff supervisions, observations and team meetings. We observed the registered manager being actively responsive to staff and supporting them. The registered manager told us they accommodated staff’s religious needs when planning rotas. The provider had an equity, diversity and inclusion policy and procedure detailing their commitment to encouraging equity, diversity, and inclusion among their workforce and eliminating unlawful discrimination.

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 systems and processes to monitor the quality of the service and worked towards improving the service. For example, the provider was strengthening their process for assessing staff’s medicines competencies. The provider had a governance policy and procedure. Audits were completed, for example, in relation to care plans, medicines and care notes.
The provider had a service improvement plan to support oversight of the service. The registered manager could describe the requirements for notifying CQC of specific incidents.
 

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. People were supported to access external professional health care services as needed such as the hospital and GP. A healthcare professional told us the registered manager contacted them often for advice, to discuss concerns, communicated well and was open and transparent. The registered manager told us families met with their operations team to discuss issues and developments.

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. There were systems in place to learn from accidents, incidents and safeguarding concerns. The provider shared learning with their teams to drive improvement.