The 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 good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation to good governance. Systems were not robust enough to evidence effective oversight of recruitment checks.

This service scored 54 (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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. Although the management recognised improvements were needed, governance and leadership arrangements were not sufficiently robust. This meant that day-to-day monitoring and assessment were not as effective as they should have been, creating a risk that the service might not always be safe or consistently meet people’s needs. The completed audits did not identify the concerns we found during this inspection.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

There was a clear staffing structure in place with a registered manager, 1 senior lead and 2 seniors managing the day to day running of the service. The registered manager had recently appointed another senior lead to enable more effective allocation of roles and responsibilities.

Some people and relatives told us the registered manager was managing the service well. A relative told us, “I have confidence in the manager. I find them very lovely and approachable.” However, another relative told us, “I struggle with the manager. She is very polite to your face, but I don’t feel she is on top of things.” Another relative told us, “I don’t know who the manager is. I don’t have any contact with them.”

We received feedback from a health professional. They told us, “The manager of the service is approachable.”

The registered manager acknowledged changes were required to make improvements to their service.

The service had a policy and processes for staff to follow on ‘whistle blowing’. The registered manager had developed a listening culture where staff felt they were available for them to talk to. This meant staff felt supported, valued and confident to raise concerns or seek guidance, which contributed to a positive working environment.

Staff told us they had regular supervisions. A staff member told us “The manager carries out regular supervision. I would have no problem talking to the manager if I had to discuss something with them. They are very approachable, and I can talk to them about anything.”

Staff meetings were being held regularly. We reviewed minutes and saw they included information about the service as well as reminders about training, staff rota’s, safeguarding and PPE. However, the action plans completed did not evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. The registered manager held regular residents meeting for people to share their thoughts about how the service was ran and if they had any concerns or suggestions. People living at the service were given opportunity to complete surveys. However, the registered manager had not analysed the results for any themes or trends, outcomes to be achieved or how results would be shared with others.

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.

There was a policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act.

The registered manager had developed an inclusive workforce and recognised the value of diversity amongst the team.

The quality assurance and governance arrangements in place were not always effective in identifying shortfalls at the service. The audits carried out by the registered managerlacked detail and were mostly a tick box exercise and did not identify the shortfalls we found. This meant effective auditing arrangements were not in place to assess, monitor and improve the quality and safety of the service provided. Care plans and staff files were not being audited regularly. Staff meeting minutes did not include action plans completed to evidence how issues raised were to be addressed, dates to be achieved and if actions had been resolved or remained outstanding. There was a lack of monitoring by the registered manager, who did not demonstrate appropriate management oversight of the service.

The service 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 management had developed good links and worked closely with health professionals. Staff were aware of the importance of working alongside other agencies to meet people's needs and liaised with other healthcare professionals such as the GP and pharmacy when required. We saw evidence confirming that the GP completed a weekly clinical round at the service each week. A health professional told us, “I have found the staff to be welcoming, friendly, and approachable, and any staff I have spoken with has been able to provide me with updates, so they seem well informed on the people they are supporting and how to support the residents. I have noted good rapport between staff and residents. The manager has worked proactively with me within in-person support plan discussions.”

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. The registered manager acknowledged that improvements were needed; however, there was no plan in place to monitor progress or drive ongoing improvements across the service. This meant there was no structured approach to identifying, addressing and reviewing shortfalls to ensure sustained improvement. The registered manager was passionate about making improvements in the service and told us, “I have recruited 2 new leads who will be able to help me support me in the service. I want to keep all staff involved throughout this process. There has been a lot of changes here and the staff know I have an open-door policy at all times, and I am here to support them. I have a really good team in place now and we are all working well together.”