Archived: Cumberland

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 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.

Staff were supported by managers to deliver consistently safe, person-centred, and inclusive care and support to people in line with the provider’s vision and values for the service. Systems and processes had been designed in line with this vision and focused on people and meeting their individual needs. Managers used audits and checks, individual and group meetings to make sure staff understood how the service’s values should be achieved through their working practices.

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 management and senior nursing team understood the context in which the service delivered care and support and embodied the culture and values of their workforce and the provider. They were experienced and undertook continuous learning and development to maintain their skills and knowledge. They also had a good understanding of the needs of people using the service and how these should be met through the provision of safe, person-centred care. People were positive about the leadership approach of this relatively new management team which they consistently described as professional and supportive. Typical feedback included, “I like the manager [registered] very much. She is always kind and patient with me”, “The manager [registered] is usually accessible and approachable whenever I visit the care home” and “The managers do listen to us [staff] and give us all the support we need”.

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

The service had an open and transparent culture. People’s feedback indicated they had no concerns or fear about speaking up if they needed to. People were provided with information about how they could report concerns and how these would be dealt with by the provider. A relative told us, “Management has consistently been approachable and effective in addressing concerns over the years and my [family members] views are regularly sought through surveys. My [family member] knows how and where to make complaints if needed.” Managers told us they explained the complaints process before people moved into the care home. Staff were supported to speak up if they had any concerns. The provider used a range of methods to gather people’s views about the care home including, regular meetings, care plans reviews and satisfaction surveys. Staff were encouraged and supported to speak up if they had any concerns.

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 were valued and treated equally and fairly. They said the managers were supportive and reported feeling respected, valued, and listened to. A member of staff told us, “I feel I’m treated fairly here.” Staff received the same opportunities to learn and progress in their roles. Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity, and fairness in the workplace.

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.

The provider operated centralised electronic systems to record and review key data and were able to identify any themes and trends developing. The provider’s quality and governance team ensured appropriate action was taken to learn from any events or incidents that occurred. In addition, the providers own internal quality assurance teams routinely conducted checks and audits at the care home including a recent mock ‘CQC’ inspection style. The review identified no major concerns and awarded the service a positive rating.

Managers understood and demonstrated compliance with regulatory requirements. They also understood their responsibility to provide honest information, suitable support and to apply duty of candour where appropriate.

We saw the service's previous CQC inspection report was displayed in the care home and easy to access on the provider's website. The display of the ratings is a legal requirement, to inform people, those seeking information about the service and visitors of our judgments.

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.

Managers and staff worked closely with relevant external health and social care professionals and bodies and regularly shared information and learning with these partners. They followed guidance and recommendations they received from these professionals to support staff learning and improve the safety and quality of the service they provided.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The service had a proactive culture of continuous learning and improvement. Audits and checks the provider conducted were routinely analysed to identify performance shortfalls and learn lessons. When lessons needed to be learnt, the provider developed action plans which set out clearly what, how and when they needed to take steps to improve the service they provided people. Staff confirmed information about any lessons learnt and action plans developed as a result were always shared with them during individual and group supervision meetings with their line managers.