Gracefields Nursing Home

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 service had a welcoming and happy atmosphere. Staff appeared to enjoy their work and supported each other well, which helped create a positive environment for people . Staff told us they valued working at the service and described a culture of teamwork. They told us they felt well supported by the management team and described being able to seek help from the registered manager and others whenever they needed it. One staff member said it was “A good place to work” with “a good team” where colleagues respected each other and where “If residents are happy then so are we”. Staff confirmed there was an open‑door policy and that the manager was approachable and available for advice.

The service was looking into a partnership with a local ambulance trust to develop a student paramedic placement programme within the service. This collaboration will support a learning‑focused culture and helps future paramedics gain meaningful experience in dementia care, strengthening their understanding of people’s needs and promoting more compassionate practice across the wider health and care system.

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 management team was visible at the service and easy for people and staff to approach if they had any concerns. Leaders were actively involved during the assessment process and engaged with people and staff throughout our visit. Visitors also told us they had positive interactions with staff and felt welcomed.

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

Individual staff supervisions helped staff take charge of their own learning and think about their work in a reflective way. Each supervision included a clear record of what was discussed and any actions or goals that were agreed. In one example, a staff member was able to share a concern, and the manager responded in a supportive way by putting help in place for that person and for other staff.

The service had a whistleblowing policy in place; however, this needed to be clearer to ensure the staff were fully confident raising concerns both inside and outside the organisation, in order to support an open culture as this is important for keeping everyone safe. The service did not have a freedom to speak up guardian, which limited opportunities for staff to raise concerns confidentially.

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 told us they worked well together and felt supported by their team. Training in equality and diversity had been completed by most staff. Plans were underway to hold an international day, where staff could share food and experiences from their cultures, to help build understanding and stronger relationships between colleagues and the people they supported. Following some historical concerns, the manager arranged a team supervision session to reset expectations around roles, communication and reporting, helping the team move forward positively. Staff who needed workplace adjustments were supported, with a flexible working policy in place.

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 manager sent notifications to CQC as required, and the service displayed its CQC rating in line with regulations. A range of audits covering the past 12 months such as falls, building checks, incidents, medicine stock and accidents were available, although some audit forms were missing signatures to show they had been completed. A care‑risk audit carried out by the service showed the service was compliant, but again, some forms had not been fully filled in to confirm completion. Some care‑planning and recording shortfalls, including inconsistent repositioning records and gaps in the written guidance for staff, had not always been fully captured through existing audits. These issues reflected weaknesses in documentation and follow‑through rather than unsafe practice, as care observed during the inspection was safe and staff understood people’s needs.

The business continuity plan explained what to do if something disrupted the service. It listed many possible risks and the steps staff should take to keep everyone safe. It also gave clear instructions on how to report problems and continue running the service during these situations.

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 service had increased its presence on social media, helping strengthen links with the local community and raise awareness of what the service offered. The provider was also planning a community‑based cinema club in one of the homes to encourage more local involvement and social opportunities.

The service initiated a new collaboration with a local ambulance trust. This focused on reducing unnecessary safeguarding referrals, improving emergency response, supporting a student paramedic placement scheme.

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 service continued to strengthen its approach to quality and culture through a range of improvement initiatives. They had developed a new policy that enabled staff to safely manage ‘long lies’, a prolonged period on the floor after a fall, while awaiting support. Learning was also supported through the use of meaningful reflective account logs, which helped staff reflect on both adverse events and positive interactions. Staff were encouraged to seek guidance and receive support after incidents, allowing managers to identify patterns and make improvements where needed.

A wider programme of cultural development was underway, with the cultural transformation project promoting personhood, communication and a sense of belonging across the service. Opportunities for meaningful engagement were strengthened through hobby‑buddy matching this helped people connect with others who shared similar interests. Another initiative called the Dream Maker was introduced to give people the chance at doing something they have always wanted with the support of the service, for example to go fishing. Digital tools such as the menu and belongings apps helped families remain involved in day‑to‑day life, supported choice, reduced waste and minimised the risk of items going missing.