Tapton Grove

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 remained requires improvement.

This service scored 61 (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. At this inspection we found some improvements in the leadership and oversight of the service. The provider had developed an action plan to address previous concerns. Staff had received closed‑culture training to help strengthen awareness of good practice and people’s rights. Auditing systems and management oversight had also improved, giving leaders better visibility of day‑to‑day practice, however this was not fully embedded. The provider had also taken steps to improve staffing stability, including increasing the number of permanent staff and reducing reliance on agency workers. Staff told us communication had improved. These improvements were still recent and not yet fully established. Further work was needed to ensure changes were sustained, consistently applied, and continued to have a positive impact on the quality and safety of the service.

Since the last inspection, the provider had taken steps to strengthen leadership of the service. An action plan had been developed, and new auditing systems had been introduced to improve oversight. However, these improvements were still recent and not yet fully embedded. We continued to find gaps in some areas, such as medicines management and the quality and completion of mental capacity assessments. This showed that leaders still needed to develop stronger, more consistent oversight to ensure safe, lawful and person‑centred care. Overall, while progress had been made, further sustained work was required to consistently improve the quality and safety of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. At this inspection we found improvements in how the service supported people and staff to speak up. People told us they felt more able to share their views, and staff said communication had improved. The provider and registered manager had taken steps to promote a more open culture, including encouraging staff to raise concerns and providing clearer routes for feedback. This included asking staff for their views on how the service could be improved and reflecting on good practice and the achievements people had made.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. Improvements were still required to ensure effective oversight the service. The provider had introduced new auditing systems to improve oversight. However, these improvements not yet fully embedded and in some instances needed to be improved. We continued to find gaps in some areas, such as medicines management and the quality and completion of mental capacity assessments, these had not been identified through the providers auditing system meaning some risks and had not been recognised or addressed. These shortfalls demonstrated that governance processes were not sufficiently effective in ensuring safe and well‑managed care. However, the provider had made several improvements since our last inspection. These included strengthening people’s care plans and the guidance available to staff about known risks, improving systems and processes for managing safeguarding concerns, and making improvements to health and safety.

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. The provider continued to work with external agencies to address identified risks, and our review of the provider’s action plan showed that progress had been made. People told us they felt more involved in planning, and activities had become more consistent. The service supported people to take part in hobbies and interests both within the service and in the community, and this was supported by up to date risk assessments that promoted people’s safety.

The provider did not always consistently focus on continuous learning, innovation and improvement across the organisation and local system. The provider had made several improvements following our last inspection, however, further work was still required to ensure these improvements were effective, embedded and consistently applied. Staff told us about the positive developments they had seen within the service, including better staffing levels and improved communication between the team and the management. People and their relatives also shared positive feedback about how the home was being managed. One person told us, “[Registered manager] is very approachable, helpful, and supportive”.