Weybourne

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.

This is the first assessment for this service. This key question has been rated 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 71 (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.

There was a warm and welcoming atmosphere in the service. The interim manager told us, “It’s a warm culture. There’s a lot of energy and enthusiasm. There’s still some work to be done like on training and supporting the team. But I would say it’s a positive culture.”

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 were aware improvements were needed. Any identified areas of improvement were added to the service improvement plan for them to work upon and record once actions had been taken.

Staff and people spoke positively about the managers who they felt was approachable and staff felt supported by the service’s management team. For example, a staff member said “The registered manager is very approachable they have an open-door policy, we have we have a really good team here. We all support each other.”

A family member said “The new manager who replaced the old one, I first met them recently they introduced themselves and wanted to know who I was. I would most likely talk to them, they seem approachable. The other one was alright, and you could speak to them about any concerns.”

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

Whistleblowing policies were available for staff with advice about who to contact if they had concerns. The interim manager told us it was also important to them to build an environment where staff felt safe to speak up. Staff meetings created opportunities for staff to be included in the decisions made in the service.

A family member said “I filled in a couple of surveys in. They sent a card out from an independent company. I can’t find anything wrong with the place. They say thank you filling out the form. I think they were checking it was a valid person filling it in.” and another family member commented “I have been to quite a few, family meetings the service do them regularly, every three months. They contact me by email. I go when I can to them or you can go on teams.”

Systems were in place for people, families and staff to feedback about the service and raise concerns. People and families commented that they felt able to raise any issues and were confident that these would be addressed. Staff did not raise that they had any concerns about sharing issues or concerns with the provider.

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 were part of a diverse team, treated equally and fairly, and they felt able to speak up. Staff told us their managers were supportive and reported feeling cared for, respected, valued and listened to by them. One member of staff said, “It is quite lovely to work here.” Another added, “We are a diverse staff team. I am treated equally, able to speak up and feel like a valued member of the staff team.”

Staff meetings created opportunities for staff to be included in the decisions made in the service

Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

Staff generally told us they felt well supported. The managers told us they had an open-door policy and wanted to encourage and support staff to learn and foster and open learning culture.

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.

There was learning undertaken. Records showed how the identified areas of learning were followed up and used to improve the overall delivery of care and support to people.

There was evidence of systems of oversight and governance in place. The provider had a comprehensive programme of audits in place, which were being completed on a regular basis, and these had the potential to identify issues when they arose, so improvements could be made. However, we found medication audits did not identify issues around fridge temperature checks. Audits pertaining to fridge checks showed the fridge temperature was recorded but there was no variant in minimum and maximum temperature, and we noted an alarm sound coming from the fridge. The staff members recording the temperature were not able to accurate demonstrate how they measured the minimum and maximum and reset the fridge. We checked this both the minimum and maximum were significantly outside the recommended ranges. We pointed this out to the interim manager who identified that the fridge thermometer was faulty and ordered a replacement fridge. . Increased governance around medicines management was needed to pick up any issues in a timely manner in order to protect people from harm.

The provider escalated notifiable incidents to their local authority and the Care Quality Commission (CQC) as required of them and promptly.

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.

There were close working relationships with healthcare professionals. The interim manager told us, “We have good relationships with the district nurses. Complex health case managers check in on us. The GP comes in every week and does a round.” We spoke with the GP who confirmed this and said, “Staff are consistent in recognising deterioration in client health state and able to take necessary steps.” There was also a link to a local school who visited the service.

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.

Regular residents and relative’s meetings were used to gain feedback on the service and where improvements could be made. The managers had a good understanding of the overall service improvement plans and they all worked in according to this plan. Staff were involved in decision making and their views and opinions sought through team meetings, staff surveys and supervision meetings. Records and minutes showed the service provider’s quality assurance processes included trend analysis of incidents and accidents. Feedback from audits, the people who use the service and staff input were used to inform learning and service improvements.