Pencombe Hall

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 improved 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 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. There was a positive culture embedded at the service. Staff spoke of being part of a strong team, who helped and supported each other in their roles. The registered manager told us the key values of the service were to be “Welcoming, homely, be open, respect each other and promote dignity. The residents come first, they are at the front of everything, it’s their home”. All staff we spoke with praised the registered manager and leaders of the service, and told us they lead by example, will offer to help when needed and encourage staff to share any concerns. One staff member told us, “Really good teamwork here, management are supportive in everything we need. It’s the simple thank you’ s and appreciation of what I do from management makes me feel the management team value what I have done for the residents. The office is always open for us – regardless of whether its personal or work-related issues, we can verbalise any concerns”.

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 and leaders had been part of the service for many years and had been an integral part of the improvements made at the service. People, relatives, staff and healthcare professionals were complimentary about the registered manager, leaders and the staff team. One relative told us, “For many years we've been consistently happy with the service they provide at Pencombe Hall to our relative. If we had any concerns, we would have conversation with registered manager or one of the seniors- they would listen and take action. We will take any chance to share how happy we are with the home”. The registered manager told us they were supported by the provider who visited on a regular basis, in the event they needed support or advice they felt assured this was always available.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People had the opportunity to raise any concerns in regular meetings. Some people also had the opportunity to share their views in 1-1 sessions with staff. Relatives told us they knew how to raise a concern and were assured, if needed any actions would be taken. One relative told us, “Anything raised, they listen, act and in a timely fashion. I haven’t raised a lot and what I have they already know and they’ve already been on it”. We saw people and relatives communicating openly with staff and managers, The registered manager understood their responsibilities under the duty of candour. The duty of candour is to be open and transparent, and it sets out specific guideline's providers must follow if things go wrong with care and treatment.

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 service promoted an inclusive and fair culture and had an equality and diversity policy in place to guide equitable and fair recruitment and selection procedures. Staff had received training in equality and diversity.

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. Audits were carried out regularly by staff, leaders, the registered manager and the provider. Incidents were logged and analysed, and lessons learnt were shared with staff. The registered manager completed a daily managers plan which included what actions were required, when these will be completed, who was responsible and what actions had already been taken. Some of these included management oversight, environmental issues, staff training and information to be shared with external health professionals. There was a contingency plan in place which provided guidance in case an issue occurred which impacted the provision of care.

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. People were encouraged to maintain relationships with those who were important to them and engage in activities which were meaningful and improved their quality of life. All of the healthcare professionals we spoke with praised the service for the care they delivered to people. The provider had links within the local and wider community and had good relationships with external providers which regularly visited the service to offer entertainment and interactive sessions. The registered manager attended local managers meetings and was part of registered manager forums, they described the benefit of sharing tools and resources with other managers in the local area.

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. The service had made improvements with medicines management and governance since our last inspection. The registered manager, leaders and staff were passionate about making further improvements, their next goal was to make some changes to the garden to make it more accessible and interactive for people living at the service. There was an open culture to share learning and drive continuous improvement to ensure people received safe, effective, person-centred care.