Coralyn House

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 inadequate. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service at the last inspection. Improvements have been made and they are no longer in breach of this legal regulation.

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 service had a positive and inclusive open culture to learning and improving. This was driven by a shared vision and set of values which all staff felt involved with and understood as it was part of their induction, displayed in the home and was discussed at team meetings.

The management team and staff provided high-quality, person-centred care. Staff worked together to promote people’s wellbeing, dignity and independence and said they felt valued in their roles. During the inspection, we observed staff providing care which respected people’s preferences and created a warm, supportive homely environment.

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.

There were clear roles which all staff understood. Staff all said they felt the service was well led by a management team which was approachable, supportive and responsive to the people and staff. Staff felt the manager was fair and supportive towards them, and they felt confident to raise any concerns, needs or difficulties, feeling they would be listened to and would be dealt with in a professional and positive manner. They felt quality and safety was monitored and actions taken to make improvements were needed, to ensure safe, effective care was provided.

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

Staff felt comfortable and confident to raise concerns and knew how to report to external sources if needed. They were confident concerns would be taken seriously and addressed promptly. Relatives also felt comfortable raising concerns. A whistleblowing policy was in place which staff knew how to access.

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 equality, diversity and inclusion. Staff had completed appropriate training and said this was promoted within the workplace. Staff told us, “Staff with protected characteristics are treated fairly, supported and given opportunities for training, development and progression.” Another told us, “The manager treats staff equally and fairly, without any discrimination.”

The provider had clear responsibilities, roles, and systems of accountability. Since the last inspection they had employed consultants to review their governance. The provider had introduced a revised governance system and an action plan to monitor implementation. However, the system was not yet complete, fully embedded or consistently effective, as outstanding capacity assessments, care plan audits and gaps in records remained. The manager was responsive when we raised any issues and rectified these in a timely manner.

We found the service acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate, to ensure people received safe, effective 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 supported to take part in community activities and continue their interests and hobbies which supported their wellbeing. The service worked well with health and social care professionals, building strong relationships, which supported person-centred care. One health care professional said, “[Staff] presented as caring and compassionate and were keen for professional advice.”

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 management team promoted a positive culture of learning and were committed to improving the service. They were working with management consultants to build a robust governance system which would give them the oversight to ensure safe, effective person-centred care was experienced by all people living at the service. There was a quality assurance action plan to manage the change and review progress. This was being done over a period of time to ensure the changes were embedded and reviewed at a sustainable rate, to ensure they were successfully implemented.

We also found the management and staff team were open and transparent during our inspection, listening and responding to any issues or concerns highlighted.