Surbitonian Gardens at Poppy Court

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 discussed with staff during their induction into the organisation, and thereafter through supervisions and team meetings. The provider had also shared their organisational values with staff and they confirmed this was done. The manager told us the organisation’s values were important to them and guided the work they did.

The provider had inclusive leaders at all levels who understood the context in which they delivered care 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 provider had recently hired a new manager who was in the process of registering with the CQC. They had worked within the organisation for some time in a different role.

Staff gave positive feedback about the new manager and told us although there had been issues caused by changing management, they always felt supported. One care worker told us “The new manager is really good. She’s worked here for a while already so everyone knows her. We just want her to stay.”

The provider encouraged a positive culture where people felt they could speak up and their voice would be heard. There was a grievance and whistleblowing policy in place. Staff told us they felt able to speak to the manager about any issues and were confident these would be resolved.

The provider valued diversity in their workforce. The provider employed a multicultural workforce and took time to celebrate different religious and cultural events. For example, they had held events celebrating St George’s Day, Ramadan, Diwali and Pride. All staff had completed equality and diversity training and told us they felt they were working for an inclusive organisation. One care worker told us, “We’re a multicultural team. We respect each others religions and background.”

The provider had clear responsibilities, roles, systems of accountability and good governance. Although there had been significant movement within the management team, roles had always been clearly defined and there had been someone in post to fulfil these. Staff had a good understanding of their roles and responsibilities. These were made clear to them when they applied for their roles and there were clear job descriptions and an organisational structure chart in place.

The provider acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. They understood their responsibilities to share information with partner agencies as appropriate.

The provider understood their duty to collaborate and work in partnership with other organisations, so services worked seamlessly for people. They shared information and learning with partners to collaborate for improvement. The provider worked closely with commissioners and multi- disciplinary professionals to monitor and improve their performance. Where issues were raised, the provider worked with others to produce and work through an action plan.

The provider focused on continuous learning and improvement across the organisation and local system. They had a clear system of audit in place where issues were identified and actions were taken to rectify any issues to improve the service.

The provider completed a number of audits on a monthly basis. Audits were completed in areas such as infection control, safeguarding and medication. When issues were identified, action plans were put in place and monitored to ensure improvements.