The Close

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 remained 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.

This service scored 61 (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 had a clear statement of purpose which set out their vision and values and these were in each person’s room so they had access to it. The staff had regular team meetings and monthly management meetings to discuss all aspects of the service. Regular audits were conducted in the service, and these were reviewed by the registered manager.

Not all leaders understood the context in which the provider delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively. The provider and registered manager did not complete out of hours spot checks on the service to ensure the continuity of service provided in their absence remained manageable and consistent. They could not be assured on the quality of care that was delivered and could not evidence how they monitored the culture in the service. We identified some recruitment gaps, however this was addressed throughout the assessment. The registered manager received regular support from the provider.

People did not always feel they could speak up and that their voice would be heard. We received mixed feedback from staff. Most staff felt able to raise concerns but some did not feel concerns regarding their workload would be listened too. The service held regular staff meetings and staff were encouraged to fill out feedback forms. However, these did not evidence that concerns were raised and addressed.

The service had a whistleblowing policy but did not always encourage people to raise concerns. Speaking to the registered manager they informed us where they had provided additional support previously and following our feedback had a plan in place to collaborate with staff to identify where the support was required and would review their policy.

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 how they had been supported with flexible working when it has been required for personal commitments. We found processes were reviewed to ensure that staff who required reasonable adjustments due to disabilities were supported appropriately.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. We found the services policies and procedures had inaccuracies in them, contact details were incorrect and there was not always a clear process for staff to follow. We identified shortfalls with them, and they were not embedded within the service. The service did complete competency checks on staff around medication and moving and handling. Other competency checks were brief and were conducted through observation rather than assessing staff competency in training they had completed.

The registered manager would ring a call bell once a week and record the response time for staff to answer. However, this was conducted the same day every week so was not an in-depth analysis. The provider told us they had arranged to upgrade the call bell system to increase the ability to analyse data properly.

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. The staff had effective communication skills using a variety of different formats within the team. The service had a good working relationship with the community. A member of the community that supports people in the service with activities, told us “in general it is a nice home to walk into, it has improved over the years, and it has a welcoming family feel. Of the hundreds of homes we go to The Close is one of the few I would recommend”

The provider was working towards continuous learning, innovation and improvement across the organisation and local system, however it was yet to be embedded with the workforce and we identified some shortfalls. We received mixed feedback from staff, but most felt they were not encouraged to put innovative ideas forward and were not listened to when they raised concerns. The service did not have robust quality assurance systems in place to ensure continuous improvement. However, all the concerns we identified throughout the inspection we discussed with the provider, and they were proactive in implementing measures to address and rectify these shortfalls.