Penley 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 as inadequate. At this assessment the rating has changed to 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 79 (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 director shared with us that when they first took over the service there had been challenges with a closed culture and risks. They felt the team had worked hard to be open and transparent and to build upon the skills of the staff.

We found the service had a welcoming and calm atmosphere and the staff team were confident and focused on improving people’s experiences, and they felt well supported by the leadership team.

The leaders led by example and the staff were all aware of the aim and vision of the service.

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 exceptional ethos, values, attitudes and behaviours of leaders and care staff ensured people led inclusive and empowered lives. People were treated with respect and dignity and staff treated people as equals.

The efforts of the leadership team in improving the service and the impact on people’s care had been recognised by people’s relatives. One relative said, “I am very, very happy with the care, they’re always very proactive.” Another relative said, “[Person’s name] has been there for years. It’s got better, especially with the new manager, on the whole, I’m happy with the way [person] is treated.”

Staff were equally complimentary. One staff member said, “It's been a massive improvement at Penley Grange for the last 2 years which I have noticed. Residents [people’s]’ life is more lively andresidents’ participation and the activities and their day-to-day life improvement has brought positive impact to the home. There is a positive response and extra hand of help always there from the management.”

We also received exemplary feedback from staff about the wider leadership team, including the director, the registered manager and the team leader. Staff told us they felt very valued and were often praised and encouraged to progress. A staff member said “I always feel we are like a family in Penley. Management team always makes that effort to make the staff and residents [people] feel as a family like a homely approach.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. One staff member said, “I have spoken up before about a concern. I felt listened to, and the manager took appropriate action and kept me informed about the outcome.” There were notices around the service on how to raise a concern, staff told us they were confident the management would take an action, and they also knew how to report concerns externally. Another staff member said, “I know how to raise a safeguarding concern both inside the service and with external agencies like the local safeguarding board or CQC.”

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 were aware of their roles and responsibilities. They told us they were able to request additional training if needed and they were able to volunteer for champion roles in line with their interests. For example, as a medicines champion or infection control champion.

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 leadership team ensured there was an effective governance system that enabled them assessing the quality of the care provided and their compliance with regulatory requirements. We saw numerous audits, for example, surrounding care planning, environment, health and safety or incidents. There was evidence the effectiveness of the governance systems was being reviewed and adjusted as needed so it remained meaningful. For example, the manager’s daily walk around used to be twice a week and then changed to once a week. There were monthly operational returns in place, which enabled the provider to share lessons learnt and good practices between the other sister services. There were also provider’s visits, unannounced spot checks and night visits.

Systems were in place that enabled leaders to review practices and make improvements ensuring opportunities for additional learning and analysis of patterns are not missed. Relevant notifications had been submitted to external bodies including to CQC as required. The provider ensured investment in the leadership training for key staff with the registered manager completing her level 5 Diploma in Health and Social Care and one of the team leaders working towards their level 4.

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.

People’s care records demonstrated the team worked in partnership with numerous external professionals. We contacted a number of professionals for feedback and received positive feedback and comments.

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.

Although the registered manager did not have experience in supporting autistic people or people with a learning disability prior to their current appointment they demonstrated their values were aligned with the statutory guidance Right Support, Right Care, Right Culture and they clearly prioritised person-centred care. After our inspection the registered manager provided a reflective practice piece to demonstrate their commitment to continuous learning and development in order to be inclusive and to empower people who used the service.

The provider worked with a number of local and nationwide agencies and partners to improve and evaluate the service.

The provider planned to extend how they actively contribute to sharing effective practice and research which had not been always possible due to the previous rating of the service hindering these efforts.