Exmoor Drive

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. The providers Statement of Purpose sets out their core values to ensure people receive a high-quality service in the right place at the right time. Core values outlined in the Statement of Purpose included, “To promote independence and to enable people to continue to live their lives to their full potential, always ensuring privacy, dignity, choice and respect whilst enabling them to make decisions. To ensure people who use our services remain at the heart of everything we do.” One staff member told us, “The people who live here are all lovely and staff work well together with good communication and as a team.” Relatives told us they would recommend the home. One relative told us, “It would depend on the individual. We like the small size of the home but with more staff as there are quick turnovers. They held a garden party which went very well, and they worked hard to make it good.” Another relative said, “I would recommend if a person had the same disability as my family member.”

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. All people spoken with knew who the management team were. One person said, “I could speak with the manager and they listen to me.” Most staff told us the management team were supportive and approachable. One staff member said, “Management happy to step in and support when possible.” We saw the manager was included on the rota between October and December to work hands on to cover shortfalls in staffing levels. Another staff member told us, “Communication is good. Team leaders provide handover and senior support worker give a whole handover of the day. We receive a lot of communication from the registered manager. For example, via emails, handovers and on the noticeboard.” However, some staff felt communication could be improved. A relative said, “Communications are good. Better now than 12 months ago, but not as good as 3 years ago.” Relatives felt the home was well-led. One relative said, “It’s sometimes chaotic, but things get done.” Another relative told us, “[Registered manager name] always has their finger on the pulse. Sometimes not available but nine times out of ten can get hold of them.” A further relative said, “They do a good job with the resources they have.” The only comment made by relatives in relation to anything the service could improve on were more activities and opportunities for people. One relative said, “Family would like [person’s name] to go out on countryside walks which they would love.” The registered manager was supported by the head of provider services, quality and compliance team leader and the team leaders within the home to help manage the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Policies and procedures were in place to support staff to speak up and raise concerns. Posters displayed details for staff to speak up. Staff told us they knew how to raise concerns and were confident any concerns raised would be listed to and acted on by the management team. One staff member said, “I would not be worried raising and reporting any concerns. If felt I wasn’t being listened to by my manager I would go higher to their manager. If still not listened to I could report to the local authority or CQC.” The registered manager was open about lessons learnt and actions taken to prevent recurrence. They understood duty of candour and their responsibilities.

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. There were processes in place to ensure staff were treated fairly and equally and their rights were upheld. For example, there was an equality policy in place to protect staff from harassment and bullying and a focus on protected characteristics under the Equality Act. Overall staff told us they felt respected and valued at work. One staff member said, “Service developing, getting better and better, staff are feeling better in self.”

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. Management checked on the quality and safety of the service. Audits and checks were carried out on key areas such as care plans, daily notes, risk assessments, medication and training. Records showed where concerns had been identified, required action had been taken appropriately to drive through improvements in people’s care. For example, we saw on the home’s action plan they had identified daily notes were really difficult to follow as writing was often illegible and records did not always give enough detail. Therefore, staff were provided with further training to support this. However, healthcare professionals shared some training needs were not always addressed promptly.

Healthcare professionals shared communication had been poor in relation to sharing information and learning for improvement. For example, information not being passed on and communicated to the team by management and in relation to management not responding to emails in a timely manner. However, they told us, “More recently communication has improved with management/senior staff members and emails are responded to within an appropriate time frame.” As a result of concerns raised about staff understanding and knowledge healthcare professionals had signposted the management team to relevant training however, this was not acted on in a timely manner therefore one of the healthcare professional’s colleagues arranged this training for staff with the palliative care nurses.

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. The registered manager was committed to improving the care provided. They had learnt from feedback from other agencies and acted on advice given. For example, in relation to sharing information. There were systems in place to share outcomes of any accidents, incidents and investigations. Managers met regularly which provided the opportunity for shared learning. This included outcomes of investigations and lessons learned to prevent similar incidents happening again.