The Coach House SBDP1 Limited

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 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 previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment, and the service was no longer in breach of this 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 registered manager told us they strived to make sure people were consistently provided with good quality care and made sure staff were properly trained to fully meet people’s needs.

Staff consistently demonstrated the provider’s values of being caring and delivering person-centred care.

A member of staff told us, “I would recommend The Coach House as a place to work and would be happy to recommend it to a friend.”

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 wider management team told us how they continually aimed to run a high-quality service for people living and working in the home.

People living in the home, their representatives, staff and external professionals were very complimentary about the registered manager, the wider management team and the ethos of the whole service.

People and relatives told us the whole management team was visible and approachable, and they could speak to them when they wished to. A person’s representative told us, “The manager is often around and I can talk to [them] whenever.” Another commented, “The manager is approachable and I can see [them] or [management team] at any time. I only have to knock on the door.”

Staff told us they felt well supported by the registered manager and the wider management team and were complimentary about the level of support they received.

A healthcare professional told us, “The manager is approachable, supportive, and clearly committed to achieving positive outcomes for residents. It is evident that they genuinely care about the people living within the service and actively promote a culture of openness, professionalism, and continuous improvement.”

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

The registered manager and management team promoted a culture of being open and honest. Staff told us they were encouraged to speak up if they had any concerns and felt comfortable doing so.

The service had effective systems and processes to help ensure people knew how and felt confident to speak up, raise concerns and whistleblow, without fear of retribution.

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 management team listened to feedback from staff through various channels such as quality surveys and team meetings. This ensured the management team and provider promoted an inclusive and fair culture throughout the service.

Staff told us they felt supported to develop their skills and knowledge and were offered training to help with career development. Staff also told us they felt the culture of the organisation was fair and open.

A member of staff told us, “The best thing about working at The Coach House is the sense of inclusion. Information is shared with staff, which helps everyone remain informed. I also find the managers approachable and fair in their judgement. They are supportive and deal with situations promptly when issues arise. In my experience, managers are generally available when staff need support.” Another member of staff said, “The Coach House has been a healthy workplace for me as a healthcare assistant. The Coach House promotes equality, diversity and inclusion to the core, which I have experienced, and I feel valued and secure.”

The provider did not always maintain clear and accessible records in respect of risk, performance and outcomes.

The registered manager was experienced and knowledgeable about their responsibilities. They also understood, and had worked hard with the wider management team, to ensure compliance with the legal regulations.

Some areas of governance were still ‘work-in-progress’ but we found significant improvements had been made since our last inspection. Audits covered areas such as medicines, health and safety, accidents and incidents, infection control and care plans. Regular safety checks and audits were also carried out for the environment and equipment. However, improvements to these areas needed to become further embedded and sustained.

A healthcare professional told us, “I have given feedback to the management team that the record keeping could be better at times. We have individuals at the care home in receipt of 1:1 care and care records do not always reflect what we are told verbally. It can also take a while for care records to be sent over to us to then review as part of our processes.” We discussed this with the management team and were assured that this was an area they were already addressing and that the improvements would be ongoing and sustained.

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’s care and support plans demonstrated that people were referred to appropriate healthcare professionals when needed. Information and guidance from external healthcare professionals was shared with care staff to help ensure consistency in providing care and support.

The service strongly encouraged partnership working. Staff supported people to attend health appointments and supported them with reviews of their care. The registered manager also promoted visitors coming to the home without prior arrangement.

A healthcare professional told us, “In my experience, the management are good and take on feedback. They accept individuals where notice has been given from other care homes and where no-one else will accept.”

Another professional said, “The staff are approachable, knowledgeable, and professional. They communicate effectively with residents, families and partner agencies, ensuring information is shared appropriately and that care is delivered in a coordinated way. They work collaboratively with external professionals and are always willing to engage in constructive discussions to achieve the best possible outcomes for residents.”

A further healthcare professional shared their views and told us, “The Coach House are one of a few local care homes that support complex people with dementia and are therefore an asset in the local community. The care home’s manager works well with our team’s ethos of person-centred approach and the use of formulation when understanding distressed behaviours in dementia.”

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 improved their systems and processes to help ensure that lessons were learnt when things went wrong. Appropriate action was being taken to ensure improvements were maintained.

Staff told us that if things went wrong, the issues were discussed during team meetings and individual support and supervisions. The management team encouraged staff members to develop by supporting them with opportunities to further their skills and training.

A member of staff told us, “We have regular staff meetings and appraisals at The Coach House. I feel there are plenty of training opportunities for us to attend and opportunities for us to better ourselves with progression opportunities.” Another member of staff said, “There is room for career growth in The Coach House, with opportunities to enrol on new training, such as NVQ levels and other personal development training.”