Belsfield House

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 service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. Staff spoke positively about the culture at this service. They said, “The (registered) manager is visible and there if there are any concerns. The (deputy manager) is available and visible.” The registered manager spoke about the core values of the service and how they’re embedded in everyday practice. They said, “Staff are trained and supported to uphold these values consistently, ensuring care is always person-centred. Our strategic priorities focus on delivering consistently high standards of care, supporting workforce development and stability, strengthening community engagement and enhancing (people’s) experience and outcomes.”

A lot of thought had gone into the design and décor of this service to enhance people and staff wellbeing. Words of encouragement were displayed around the service to motivate staff and make them feel included. We saw evidence of relative meetings taking place where the registered manager had arranged an expert in Lasting Power of Attorneys to speak to relatives and guide them through this process. Feedback from this meeting included, ‘Fabulous leadership team. Their belief is that everyone is special and deserving of empowerment.’ A service user guide was in place which held information about the service such as mealtimes and detailed the services core values which were compassion, dignity, kindness and everyone is special. These values were also discussed during staff supervision and were displayed around the service.

Staff were receiving regular monitoring and supervision. Throughout the year staff observations were recorded including observations of moving and handling, decision making and person-centred care. This gave managers an opportunity to sit down with staff and highlight any areas of concern and good practice. In addition to this, staff also received formal supervision where these observations were discussed along with reflections of workload, wellbeing and any concerns a staff member may have. Both observations and supervisions were detailed and highlighted the services core values.

The service 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 spoke positively about the management team. One staff member said, “The (registered) manager is good, they know what they’re doing, the deputy (manager) does a walk around every day, and the floor managers and clinical lead is always around.” Another staff member said, “All managers on every level are approachable.”

There was a positive culture at this service where staff felt listened to. We saw evidence of staff meetings and questionnaires that were sent to staff which had generally positive feedback. We spoke to the registered manager about how they would respond to any negative feedback, and we were told meetings and discussions would take place. We observed both the registered manager and the deputy manager communicating with people and it was clear they both knew people well and people were familiar with them.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of the term freedom to speak up and felt confident in raising concerns should they need to. One staff member said, “If I had concerns, I would inform my line manager. Staff meetings are put in place if there is something wrong.” A whistleblowing policy was in place to guide staff on what to do should they have any concerns. A poster on whistleblowing was displayed in a communal area.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff told us they were treated fairly and the registered manager told us they supported staff with reasonable adjustments including adjusted working hours, additional equipment, modified uniforms or footwear and flexible rota arrangements. Staff had completed training in equality and diversity and there was a supported policy for this.

The service had clear responsibilities, roles, systems of accountability and good governance. However, we found some governance systems needed to be improved. Various policies and procedures were in place, but some needed updating to reflect the current ways of working. Checks to the environment were being carried out but they did not identify the concerns we found during our site visit including confidential information not secured and chemical products within people’s reach. The Care Quality Commission rating that was displayed was not the most current rating. These concerns were rectified during the assessment process.

Staff praised the management team and their involvement in the running of the service. They said, “The (registered) manager is available any time we have concerns and visits a lot. The deputy manager is supportive. I have worked here for a while because the management here are good.” A range of quality checks were being carried out to ensure good, effective systems were in place as well as a range of audits that were being carried out on different managerial levels. An email was sent to the registered manager each week which included the plan for the week, any upcoming meetings or training needs and to share any concerns. The registered manager reviewed risks including hospital admissions, falls and behavioural incidents to help reduce future risks.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. People and their relatives told us people could access the community with staff support as and when they choose. One relative said, “They (people) go to the church down the road for social activities.” Relatives also spoke of how people were supported by healthcare professionals such as social workers and specialised nurses when needed.

Staff told us people could access the local community and staff ensured people went out often. They said, “We have trips out most days to the prom, café, pub, church service. Some people like to go out for dinner once a week, they choose where they want to go. A church service also visits.” Care plans held a list of important contacts such as social workers and advocates. The registered manager worked closely with various partners including the learning disability team to help enhance people’s life and wellbeing. Partnership working also ensured continuity of care and improved systems and processes. Partners told us the service engaged in forums and events designed for learning.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff told us relatives were involved in all aspects of the service, including attending meetings and events. The registered manager spoke of the importance of robust quality assurance framework including audits, feedback, governance meetings and oversight from external professionals where applicable. They said, “Staff are encouraged to develop their skills through formal training and by taking on champion roles in areas such as infection control, dementia care, dignity, safeguarding, training and end of life.” Champions lead on audits, staff training and act as a point of reference in their designated areas.

We saw evidence of concerns raised shared amongst the staff team to ensure robust lessons learnt processes as well as lessons learnt meetings which took place every time an incident occurred. A lessons learnt policy was in place and a lessons learnt file was in the office. However, this contained names of staff who had made an error. The registered manger admitted names should not be made public for all staff to see and stated this was an oversight. This was rectified during the assessment process.