Walsingham Support - 19 Beech Avenue

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.

The provider had a clear vision for the culture and direction of the service. This was reflected consistently through its policies and procedures, information available on the website, and the messages communicated to staff during induction, training, and organisational events. The provider's values and expectations were evident across the service.

The recently appointed registered manager demonstrated a strong commitment to embedding and sustaining this culture within the service, supported by the provider. During the inspection, we were particularly impressed by the importance the registered manager placed on ensuring the provider's values were translated into day-to-day practice and positively impacted on the quality of people's lives.

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 registered manager demonstrated the skills, knowledge, and experience required to lead the service effectively and was committed to achieving the best possible outcomes for people. They were reflective, motivated, and focused on driving continuous improvement while maintaining a person-centred culture.

Staff spoke positively about the impact the recently appointed registered manager had made, describing improvements in communication, leadership, and support. Feedback indicated the registered manager was visible, approachable, and committed to working alongside staff to embed the provider's values and improve people's experiences. Their leadership promoted an open, inclusive, and positive culture.

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

The registered manager and staff team recognised the importance of understanding each person's unique way of communicating and used this knowledge to help ensure people's voices were heard.

People relied on staff's understanding of their individual communication methods and behaviours to ensure their views, wishes and preferences were understood and represented.

There were systems in place to encourage staff to share their views and raise concerns. A recent staff survey had been distributed to gather feedback, and regular team meetings provided opportunities for staff to contribute ideas. These arrangements supported an open and inclusive culture where feedback was valued and used to inform improvements.

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.

Evidence demonstrated that recruitment procedures were clear and promoted equality, diversity, and inclusion. Staff consistently reported feeling respected and included within the workplace. In addition, some staff shared examples of their own personal experiences and described the additional support they had received from the provider.

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 clear governance and oversight arrangements in place to monitor the quality, safety, and effectiveness of the service. Systems were established to identify areas of good practice as well as opportunities for improvement, supporting a culture of continuous development.

Regular mock inspections were undertaken and provided a robust oversight of the service. These identified strengths and areas requiring further attention, with detailed action plans developed to drive improvement. The registered manager had made significant progress in addressing the actions identified and demonstrated a strong commitment to completing these in a timely manner.

Governance oversight was further strengthened through support from the provider's quality team and senior leaders. This provided additional scrutiny, guidance, and accountability, helping to ensure improvements were sustained and embedded into practice.

Quality assurance and performance issues were discussed regularly with staff and featured as standing agenda items at team meetings. This supported a positive culture where continuous learning, accountability, and high-quality care were promoted throughout 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.

The provider and registered manager worked collaboratively with a range of partner organisations, including health and social care commissioners and healthcare professionals. They maintained positive and constructive working relationships with those involved in people's care and support, promoting a coordinated and person-centred approach.

The registered manager recognised the importance of partnership working and continued to engage proactively with external agencies in response to feedback and concerns the home had received and to support positive outcomes for people.

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 demonstrated innovation across the organisation and a clear commitment to continuous learning and improvement. The provider was actively involved in a range of initiatives aimed at improving outcomes for people.

Examples included supporting people to have a voice and contribute to issues that affect their lives through The People's Parliament, and engagement with Alzheimer's research initiatives.

There was a culture of learning, collaboration, and innovation, with a clear focus on identifying new opportunities to enhance the quality of the service and increase positive outcomes for people living in the home.