Sutton Grange

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 changed to requires improvement. This meant the governance and oversight was inconsistent and did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 62 (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 visions and values of the home were clearly defined in the employee handbook, ‘To provide a premium caring experience, delivered by our great teams to those we care for.’ Staff were also signposted to the ‘Code of Conduct for Adult Social Care Workers in England’, which outlines expected standards and behaviours.

The registered manager carried out regular walk arounds, and the regional director visited monthly, to monitor staff interactions and the culture at the home.

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 deputy manager were visible, led by example and modelled inclusive behaviours. A person living at the home told us, “[Registered manager] is reasonably new but very easy to speak to and is often out speaking to people.” Another said, “I know [registered manager], and can talk to them, they are extremely good.” Staff spoke positively about the registered manager and deputy manager.

The provider ensured managers were provided with ongoing training and support; to continuously improve their knowledge, skills and capabilities. The registered manager had completed an appropriate induction and a variety of training. They attended meetings with other managers, and monthly zoom calls to improve their knowledge and stay up to date with changes to best practice guidance and regulation.

Arrangements were in place to encourage succession planning. Staff confirmed they had access to ongoing learning and professional developmental opportunities.

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

The provider encouraged a culture of speaking up about concerns and prompted the value of doing so. Staff were given the opportunity to speak up via team meetings, surveys and supervisions. ‘You said, we did’ posters detailed actions taken in response to concerns raised about staff morale, recruitment and the home environment.

Managers were open to feedback and staff felt supported to speak up, without the fear of detriment. A staff member said, “[Managers] encourage staff to report concerns without fear of retribution. I am encouraged to speak up.” Another added, “I feel ok to raise concerns.”

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 provider took action to prevent and address bullying and harassment. Staff had access to the employee handbook which included information around bullying and harassment, equality, diversity and inclusion and grievances.

Staff, including workers from overseas confirmed they felt fairly treated, and expressed no concerns about equity or the culture at the home. Most staff spoke positively about their treatment from managers and colleagues. A staff member said, “The staff are wonderful, it’s a really good team. It’s a nice place to work.” Another told us, “Staff that I have met are very nice.”

The provider did not have clear governance systems or act on best information about risk or outcomes, but there were clear roles, responsibilities and systems of accountability, and information was shared securely with others when appropriate.

The provider had a variety of checks and audits in place to ensure governance and oversight, but these had not been effective at identifying and/or addressing concerns found during our inspection. For example, gaps to care records and monitoring, and issues with medicines management.

There were arrangements for the availability and confidentiality of data and records, but the integrity of information was not always robust, or used effectively to monitor and improve the quality of care. Information in care plans and risk assessments was not always correct, consistent or contemporaneous; and gaps to care records and monitoring of fluids or people’s health had not been identified.

Plans were in place to ensure business continuity in case of an emergency or adverse event, and notifications were submitted to the appropriate agencies as required.

Following feedback, the registered manager explained the electronic care planning system in use was still being embedded, and additional training had been organised to ensure record keeping improved. Several improvements to medicines management systems were implemented immediately in response to our findings.

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.

Managers and staff understood the importance of working in partnership with others, sharing information and learning, and collaborating for improvement. The registered manager explained how they collaborated with other managers, to share information and learning; and they were looking to support a local volunteer scheme to help improve socialisation at the home.

Sutton Grange was embedded within the community and considered a valued partner by others. The home hosted weekly sessions for a local dementia choir, and had held a Hawaiian party for people, including those supported by other care providers. Visits from local schools and baby and toddler groups were organised, to give people the opportunity to meet others and develop positive relationships in the local community.

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.

Staff were supported to prioritise time to develop their skills around improvement and innovation. Several staff acted as company ‘champions’ to drive improvement within the service. The registered manager explained the IPC champion had previously attended local authority training sessions.

The registered manager confirmed there was adequate investment in the service, to ensure improvement could happen. Several recent enhancements to the environment had been made, such as improved gardens, murals, dining and balcony areas. High planters had been installed to ensure gardening activities were more accessible, and a gazebo had been built following a request from a relative.