Welbeck 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 Good. At this assessment the rating has remained 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 71 (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.

People and relatives described a positive culture within the home. A relative told us, “They are proactive and listen to us”. Staff also described a appositive culture. One staff member told us “We have a good team here that works well together. Feel proud to empower and allow people to become independent. The manager is good, she is very supportive and an active listener.” Staff demonstrated they understood the vision and values of the service. The leaders of the service had a good knowledge of the provider’s vision and values for the service. The registered manager told us, “We put people first. That is what we value. We value people and their rights.” Regular supervisions, training, reflective practice and an effective induction helped to ensure staff felt supported and equipped to carry out their care roles. Staff also told us they felt they worked well as a team. The management team operated an ‘open door’ policy where people, relatives and staff could speak to them at any time to ensure there was an open culture where concerns could be raised and acted upon.

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 registered manager had been in post for several years and worked alongside a number of other staff who had also been employed on a long-term basis. This meant there was a stable and effective management team. Staff were committed to people and enabling them to live their best lives. They demonstrated a caring and compassionate approach to people, staff and relatives.Staff told us, “Management are approachable. They have the right knowledge and skills to support me. Management are hands on and visible around the home. If we are worried about something we can go to them and they support and help direct.”

The registered manager understood the duty of candour and their responsibilities.

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

Systems were in place to ensure people who spoke up were supported and staff told us they felt confident to raise any concerns with the registered manager. One staff member told us, “Leaders encourage us to speak up”.The provider had a policy in place to support staff to raise concerns, have freedom to speak up and whistle blow. The policy gave guidance to staff on how to raise concerns and assurances these would be taken seriously and investigated appropriately.

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.The provider had a policy to support equality and diversity. The policy ensured all staff worked in an environment which was free from harassment and discrimination. The policy set out how staff would receive equal treatment regardless of their protected characteristics in all aspects of their employment.Staff told us they felt valued, supported, and worked as a team, describing a positive and inclusive workplace culture. These values were supported by a consistent approach by the registered manager, regular supervisions, and staff meetings.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Although systems were in place to assess, monitor, and improve the quality and safety of the service, further improvements were needed. The provider operated an audit system which was routinely reviewed. The service’s internal governance arrangements had not identified gaps such as discrepancies between medicines stock levels. However, where other audits had identified improvements required such as the environmental and maintenance audits, we saw evidence of the registered manager being proactive to take action.

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.

Partners told us no concerns had been identified about how the service worked with them. The registered manager and staff demonstrated they understood the importance of working collaboratively with other professionals. Referrals to health and social care professionals were made when required and the provider worked collaboratively with professionals when people’s needs changed. This helped to promote positive outcomes for people using the service.

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. There were systems in place to monitor quality and inform learning and improvements.The manager was engaged and proactive in ensuring the service continually improved. We saw a scoring method used by the registered manager whereby they used CQC’s previous Key Line of Enquiries (KLOE) system and scored different areas such as care plans to determine whether any improvements were required. The registered manager told us if a good score was not achieved, they would look at their processes to make improvements.