Grenham Bay 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 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.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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’s website states, ‘Our mission is to bring hospitality, care, independence and support to our residents.’ Staff understood the aim of the service and their role within it.

Staff told us, they involve people and their relatives as much as possible. The registered manager had processes in place to make sure staff were aware of the provider’s policies.

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. Staff and relatives told us, the registered manager was approachable and visible at the service. The registered manager worked with staff when there was sickness or senior care cover needed.

The wider management team were often present at the service. The nominated individual spent time each week at the service, to complete checks. When the registered manager was on leave the group support manager had oversight of the service. All members of the management team completed regular spot checks at night to check how staff were supporting people and to discuss any concerns they may have.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff were given the opportunity to attend meetings and complete surveys. Relatives told us they had attended the meetings and had been given the opportunity to express their views and suggestions. Relatives told us they knew how to raise concerns, and they could speak to senior care staff or the registered manager when they needed to.

Staff told us they could raise concerns and felt they were listened to. The introduction of ‘walkie talkies’ was in response to staff raising concerns about communication between staff during busy times.

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. The provider had policies in place to promoting equality. Staff told us they were treated fairly and their commitments outside of work were considered. The registered manager told us, staff generally organised their own duty rota, which they checked. This had supported staff to understand each other’s needs.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.There were processes in place to check the quality of the service and identify shortfalls. However, these had not always been effective in making sure action was taken.For example, the nominated individual had identified the care plans needed improvement. During the onsite visit, we spoke with the group support manager about the poor risk assessments and lack of guidance in the care plans. They confirmed they knew about the issue and some improvements had been made but the shortfall remained, placing people at risk.

The provider completed weekly visits to the service, which were recorded, but the reports lacked detail. For example, there was no information about what was found when care plans had been reviewed. There had been a mock inspection completed which had identified areas which needed improvement, but there was no detail as to the improvements needed. For example, a section asked, ‘All Resident Care Plans are regularly reviewed, up to date and reflect their latest needs’ the comment was ‘some improvement needed.’ There was an action plan in place, but this did not include the shortfalls found at this assessment. At the time of the assessment, the shortfalls continued to be present.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. People were supported to be part of the local community and visited local places of interest. People were referred to other agencies when needed and staff understood their responsibility to share information to support them.

The provider did not focus on continuous learning, innovation and improvement across the service. There had not been a culture of continuous improvement since our last inspection, and the quality of the service had declined.

There was not a clear plan to drive improvement within the service to include innovation to improve the service for people.