Tolson 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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 57 (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 vision and values statement which was shared and discussed with staff at interview. The vision and values were part of weekly communications from the provider which were made available to all staff. Staff were clearly aware of the values as a member of the team told us. “Anchor values have helped me improve in my work."

Leaders did not always embody the culture and values of their workforce and organisation.

Feedback about the management team was varied. Some people and relatives and staff felt the manager was approachable and listened to them, whilst others felt they had a detrimental effect on the staff team which was why they were losing staff.

Staff also varied in their feedback about managers. Some felt listened to and supported whilst others felt there was a culture of punishment and did not feel valued.

Leaders were supportive of the assessment process and demonstrated an open and honest approach.

People did not always feel they could speak up and that their voice would be heard.

Not all staff felt confident that they would be listened to if they spoke up. One said, “I don’t think anything gets actioned. Staffing is not dealt with, and a lot of staff are fed up”. Staff were aware of the senior management team and knew they could approach them if they needed to.

People and relatives felt they could speak up if they needed to. One relative said, “I know [registered manager], I can speak to her, she’s approachable.”

The provider valued diversity in their workforce. They did not always work towards an inclusive culture by improving equality and equity for people who worked for them.

The provider employed a diverse staff team including different ethnic backgrounds and genders. Although there were systems in place to involve staff and gain their opinions, for example meetings and satisfaction questionnaires, staff did not always feel valued and included.

The provider did not always demonstrate good governance. They did not always act on the best information about risk, performance and outcomes.

Governance systems were in place; however, they were not always effective in identifying issues within the service. Our assessment identified several shortfalls that had not been recognised or addressed by the quality management systems. These related to risk management, oversight of care records, and the promotion of people’s dignity.

Potential breaches of confidentiality had not been identified. Staff were using a social media group app on their personal phones, where private and confidential information about people using the service was often recorded. Issues relating to safe management of medicines had not been picked up through auditing which resulted in us identifying a breach of regulation.

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.

Partner agencies did not report any concerns about the service, with one telling us how well they had worked collaboratively to support a person and their family.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Some opportunities for learning and improvement were missed due to governance systems not always being effective. The management were receptive to the assessment process and, wherever possible, put systems of learning in place for all staff.