Tadworth Grove Care Home

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 requires improvement. 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 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 based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Most people we spoke with knew who the registered manager was and were positive about them.

The registered manager worked with senior managers and the staff team to meet people’s needs. They told us, “We try to meet people’s needs at all times and ensure they have a happy life here. I have a good support from upper management, the compliance team. If there is a new policy coming up, we get involved and informed. I am happy here.” A healthcare professional stated, “Staff in general are kind and patient. Residents’ needs are met well.”

Staff were listened to and their comments and suggestions were taken seriously. The provider had put in place a ‘We said…we will’ system. For example, they had identified that team building had improved how the staff team related to each other and worked together. As a result, team building exercises took place on a quarterly basis.

The management team told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. Staff told us there was a good and positive culture within the home where people and staff had a good rapport, and the atmosphere was one of respect and care. A member of staff commented, “The home is fully transparent regarding any concerns raised. Very supportive management team.”

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

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.

Overall, people and relatives were positive about the management team. One person told us, “[Registered manager] is approachable” and “I have been to [Registered manager] about [concern].” The person told us they felt listened to and their concern taken seriously.

Staff found the management team to be visible and supportive. One staff member told us, “The managers are very supportive. The door is always open and there’s a listening ear. I am supported by the deputy and management team. Our views are respected.” A healthcare professional told us, “The management are almost always on site and will often make time to speak to me. I am confident in their abilities and trust their judgements.”

The registered manager was experienced and had worked their way up from care worker. They told us, “I have a post grad diploma in management and have completed my registered manager’s award. I keep up to date with everything else, such as training. My deputy has been here 9 years, [they] started as a nurse.”

There was a staff newsletter issued regularly. This included any relevant information and news about the service.

In addition to monthly staff meetings, there were daily handover meetings to discuss important information and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

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

People were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint.

Staff told us they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home.

The provider had some processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up. The registered manager told us, “Staff have the ‘speak up’ phone number from [Provider] so they can speak to someone if they need to. My door is always open if they want to speak with me. We have a structure whereby the nurses supervise the carers etc. My manager spoke to the staff to ask if they were happy with the culture and if they wanted to raise anything. Nothing came back.”

Staff were consulted and had the chance to speak up about any concerns they may have. They received regular supervision from their line manager and were consulted via yearly surveys. The last staff survey showed they were happy working for the service. A member of staff told us, “We can raise concerns and can use the speak up policy. Concerns are acted on. Residents are our priority."

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 enjoyed working in a diverse team. A member of staff told us, “Staff respect each other. We are encouraged to be open. We have regular team building exercises.”

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. The registered manager told us, “I support one staff with [specific need]. We also have staff from other backgrounds, we have team building sessions to help ensure they are all involved. We get to know them. We have ice breakers, so they get to know each other.” They added, “We make sure all staff know we would support them if they had specific needs. We don’t currently have anyone from the lesbian, gay, bisexual, and transgender (LGBT+) community, but staff are given advice on where to access any information or signposted to where they can have support."

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.

Staff told us they felt supported and valued by the registered manager who was available whenever they needed them. Staff said they were supported to keep up to date with the care people required.

The provider had robust monitoring systems in place. There were trackers in place to help ensure audits were undertaken regularly and were up to date. Audits included, accidents and incidents, Deprivation of Liberty Safeguards (DoLS), health and safety checks, fire checks, medicines and care plans. DoLSensures people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty. The management team conducted daily walks around the home to check the environment and talk to people and staff as needed.

The registered manager ensured the management team was visible within the home and available when needed. They told us, “My deputy works 2 days on the floor so she can always see what is going on there and support the carers.”

The provider ensured communication was effective. There were weekly clinical risk meetings, where the managers and nursing team discussed any risk identified and any actions needed. There were also monthly heads of department meetings, quarterly staff meetings and quarterly residents and relatives’ meetings. A relative told us, “There have been meetings, but I wasn’t able to attend. [Deputy manager] keeps me informed about what is going on. They are brilliant. My [family member] was in a home and all they did was sit and stare at one another all day. It was nothing like this place. I would be happy to live here if I needed care."

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.

Staff told us they regularly worked with healthcare professionals so people’s needs would be met. The registered manager confirmed they had a good working relationship with a range of external professionals. They told us, “We have meetings with other care home managers so we can talk to each other, share good practice and any projects we might have. The local authority arranges those meetings. We shared our quality assurance plan.” A healthcare professional told us, “[Registered manager] is a thoughtful manager who creates a positive environment.”

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The registered manager told us they ensured the staff learned from healthcare professionals involved in people’s care to help them better understand people’s needs.

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.

People told us they were consulted individually during a review or regular conversation, or as part of a ‘residents’ meeting’, to find out if they had any concerns or requests. We saw people’s opinions and requests were taken seriously.

Staff said the managers were always aiming to make improvements to the service in order to benefit people and they enjoyed being part of this. A member of staff told us, “The culture is to make residents the centre of care. They come first. To help them live longer and happier. To promote their dignity.”

The registered manager was committed to make every day meaningful for people. They told us, “If we make mistakes, we learn from them. We make sure the staff are able to help with decisions and people are happy.”

Staff were given ‘reference cards’. These were quick references to a range of areas staff could access when they needed information. For example, the ‘8 rights of medication’, fire safety, MCA, safeguarding adults at risk and how to speak up.

The provider had put in place a STAR program. This stood for See, Tell, Act and Report. The purpose of this was for staff to be more observant and report on anything of concern, so that quick action could be taken. We saw the staff had taken this seriously and had reported a range of observations to management, such as a bruise on a person, and another who seemed to have developed a dry cough.