1 Sheringham Avenue

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 outstanding. At this assessment the rating has remained outstanding.

This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 89 (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 promoted a positive, inclusive and person-centred culture across the service. People and their relatives told us they were happy with the care provided and described a supportive and respectful environment. Staff consistently demonstrated values that placed people at the centre of care and promoted dignity, independence and wellbeing.

Staff spoke positively about working at the service and described a culture where they felt valued and supported. They told us they enjoyed their roles and would recommend the provider as a place to work and to receive care. This reflected a motivated workforce aligned with the provider’s values.

Staff understood the direction of the service and the expectations of their roles. They described clear leadership and oversight, including regular feedback and opportunities to reflect on practice. One staff member said the service manager is, “always very supportive,” and explained that managers carried out spot checks and “provide feedback,” which demonstrated active leadership and a culture of continuous improvement.

This meant there was a strong, shared culture within the service, where staff were supported, values were embedded in practice and people experienced consistently positive care.

The provider promoted a culture where people were valued as active contributors to the service and wider organisation. For example, some people were supported to act as ‘quality checkers’, visiting other services within the organisation to provide feedback on quality. This enabled people to share their views beyond their own home and contribute to service improvement.

Staff described how people were supported to prepare for these visits and share their views in a way that reflected their communication preferences. As a result, people developed increased confidence, communication skills and a stronger sense of purpose, as they were able to contribute meaningfully to improving services for others.

Feedback gathered through these visits was used to inform service improvements, demonstrating that people’s views were not only sought but acted upon. This approach reflected a strong culture of co-production, where people’s lived experiences were valued and used to shape practice across the organisation.

Leaders demonstrated a high level of skill, experience and understanding in overseeing the delivery of care. They were visible within the service and actively involved in supporting both people and staff. We observed a strong leadership presence, with senior staff approachable and engaged, contributing to the smooth and effective running of the home.

Relatives spoke very positively about the leadership of the service and expressed confidence in how it was managed. They described managers as accessible and responsive, and told us they felt able to raise questions or concerns at any time. One relative described the management as, “absolutely brilliant,” while another told us, “Clearly care about their residents. We are very lucky to have this home,” reflecting the high regard in which leaders and the service were held.

Staff consistently told us managers were supportive, approachable and promoted an open culture. They felt listened to and valued, and described a leadership style that encouraged discussion, reflection and continuous improvement. One member of staff said “[Registered Manager] is really approachable and supportive. I feel like I can go to him about anything. He listens and values my opinion. Since he joined he created like a really open environment where we can just speak honestly, share ideas, and raise concerns without feeling worried about it. It just feels like a positive place where everyone’s respected.”

Leaders demonstrated a clear understanding of people’s needs and the importance of delivering high-quality, person-centred care. They promoted inclusion and ensured people, relatives and staff were involved in decisions about the service. This created a culture where people felt respected, supported and empowered.

This strong, visible and compassionate leadership ensured the service was well-led, with high standards maintained and continuously improved, resulting in consistently positive experiences and outcomes for people.

The provider had a strong and open culture where people, relatives and staff were encouraged and supported to speak up if they had concerns. Systems and policies were in place to ensure concerns could be raised, listened to and acted upon, promoting transparency and continuous improvement.

Relatives told us they felt confident raising concerns and that issues would be addressed appropriately. One relative explained, “If I did [have a concern] I would tell the manager and I know they would listen to me,” which demonstrated trust in the leadership and responsiveness of the service.

Staff also understood their responsibility to raise concerns and described clear processes for doing so. They told us they could raise issues with managers and escalate externally if needed. One staff member explained concerns could be reported to external bodies such as CQC or the local authority if required, showing awareness of whistleblowing procedures and accountability.

This open and supportive culture meant people and staff felt safe to speak up, confident that concerns would be taken seriously and used to improve the quality of care.

The provider promoted a culture of equality, diversity and inclusion within the workforce. Systems and processes were in place to ensure staff were treated fairly and with respect, from recruitment through to ongoing support and development. Staff told us their individual needs were recognised and accommodated, including requests for flexibility where required.

Staff spoke positively about the inclusive culture of the service and described a respectful working environment. One staff member told us, “Staff are respectful. Various backgrounds but all respect each other,” which demonstrated a workforce where diversity was valued and supported.

Leaders encouraged open communication and sought feedback from staff through discussions and supervision, helping to ensure individual needs were understood and addressed. Staff felt able to raise any concerns and were confident they would be supported.

This meant the provider had created an inclusive and supportive working environment where staff from diverse backgrounds were respected, valued and enabled to carry out their roles effectively.

The provider had highly effective and well-embedded governance systems that drove continuous improvement and sustained outstanding standards of care. There was a proactive and systematic approach to monitoring quality, with regular audits across all areas of the service, including care planning, medicines, health and safety, and the environment. These were used not only to identify issues but to anticipate risks and embed learning.

Leaders demonstrated strong oversight and a clear understanding of the service. They used a range of information, including audits, feedback and performance measures, to evaluate the quality of care and drive improvement. Where areas for development were identified, timely and effective action was taken, with clear accountability and follow-up to ensure improvements were sustained.

Staff described visible and engaged leadership, with regular checks and feedback supporting high standards. One staff member told us, “[Registered manager] does spot checks and provides feedback,” reflecting active oversight and a culture focused on continuous development.

The provider actively sought and responded to feedback from people, relatives and staff, using this to shape and improve the service. This inclusive approach ensured a wide range of views informed decision-making and service development.

This strong governance framework, combined with proactive leadership and a culture of continuous improvement, ensured the service consistently delivered high-quality, sustainable and person-centred care.

The provider worked proactively in partnership with a range of professionals and organisations to ensure people’s needs were met and outcomes were improved. Staff liaised effectively with healthcare professionals, including GPs and other services, to monitor people’s health and ensure timely access to support.

People confirmed they were supported to access healthcare services when needed. One person told us staff would provide, “support to take me to GP and other appointments,” demonstrating how staff worked alongside external professionals to meet people’s health needs.

Staff demonstrated a clear understanding of the importance of partnership working and described how they communicated with professionals to share information and respond to changes in people’s needs. This collaborative approach supported coordinated and consistent care.

The service also benefitted from working across the wider organisation, with staff sharing knowledge, experience and best practice with other teams. This supported continuous learning and improvement across services.

This meant people benefited from strong, effective partnerships that supported their health, wellbeing and inclusion in the community.

The provider demonstrated a strong commitment to continuous learning, improvement and innovation. Systems were in place to support staff to reflect on practice, develop their skills and embed learning across the service. Staff were supported by experienced and knowledgeable senior staff to improve practice in key areas, including health and wellbeing and medicines management.

Staff described a culture where learning was encouraged and shared. They told us training and ongoing development supported them to improve how they delivered care. One staff member explained, “we discuss it [issue] and we all know how to improve,” reflecting a proactive approach to learning from experience and embedding improvements into practice.

Learning from incidents was embedded within the service. Staff reviewed incidents and near misses to identify themes and areas for improvement, and changes were made to care plans and risk assessments where required. Learning was shared across the team through handovers, meetings and supervision. This approach helped reduce the likelihood of recurrence and improved the consistency of staff responses, supporting safer and more effective care for people.

The provider also engaged with external learning opportunities to improve practice. For example, the service participated in a medicines optimisation audit with the local integrated care board. This supported staff to review prescribing practices, reduce unnecessary medicines and improve oversight of medicines that were not being taken. As a result, people benefited from safer and more appropriate use of medicines, and staff developed a greater understanding of medicines management.

Innovative approaches were used to further embed person-centred practice. For example, people were supported to contribute to their own daily records, ensuring their views and experiences were reflected in care documentation. This approach supported people to have greater ownership of their care and improved the accuracy and relevance of records.

The service had achieved Autism Specialist status through the National Autistic Society Autism Accreditation programme (June 2025). Staff told us this had strengthened their understanding of autism and supported more consistent, tailored approaches to care, particularly in relation to communication and sensory needs. This learning had been embedded into practice, resulting in more personalised and effective support.

This strong focus on learning, reflection and innovation meant the service was continuously improving. Learning was actively applied to practice, resulting in safer care, more consistent support and improved outcomes for people.