Abbey Dean

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 75 (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 provider had clear values which were embedded into the staff team. These were promoted by the registered manager, who had built an open culture fostering an environment where practice could be shared, concerns raised and lessons learnt from. People received a high level of care from a staff team who were passionate about supporting people in all aspects of their care. For example, staff spoke with fondness about the people they were supporting and were able to describe their individual needs whilst focusing on their strengths and preferences. By creating multiple channels for people, staff and relatives to provide feedback a strong culture of inclusivity had been developed. People consistently told us they were happy with the support they received from staff and spoke about the benefits of a multicultural environment. One person said, “The staff are from different places, and I like all of them, I’ve learnt so much about different cultures during our conversations.” The culture of the home was further promoted by celebrating achievements of staff with an employee of the month award, alongside sharing important moments in life when staff and people came together for meals and activities.

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 was visible, accessible, and actively engaged with people, they were highly regarded by people, staff, relatives and professionals who gave consistent feedback around their approachability and leadership. These included, “I was new to the role and when there was an emergency, I rang for help and [registered manager] got involved and took the lead, then went through it with me and the other staff teaching us how to respond, its helped me know what to do and raised my confidence.” And a professional said, “[Registered manager] goes above and beyond in her role. I work with many managers and find her to be very caring, knowledgeable and supportive about the residents.” The registered manager held team meetings for staff discussing various agenda points including learning from incidents, this provided consistency across the team. A staff member said, “We have staff meetings and we speak about things going well and challenges we may face.”

The staff team was structured with roles in place to provide consistent oversight of people’s care and provide frontline staff with support. A staff member said, “If I ever need advice or support about a person’s care there always a senior member of staff to ask and we have an on-call system as well.”

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

Staff told us the registered manager encouraged them to speak up and felt confident raising concerns and that their voices would be heard. Comments included, “[Registered manager] reminds us to tell her about issues if they happen.” And “There's an open-door culture, I’d be happy raising a concern if I needed to.” Channels were in place supporting staff to provide feedback including team meetings where topics were discussed and practice shared. Staff received regular supervisions and could feedback in surveys. Where appropriate people’s relatives had access to remotely view their loved one’s care plans supporting their ability to speak up and participate in care reviews reducing barriers around distance.

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 workforce contained a diverse mix of backgrounds and skills. Staff received an induction into their roles alongside ongoing support from the registered manager. Staff consistently told us they had opportunities to enrol in courses including NVQ’s to further their professional development including other training staff had an interest in promoting their participation in raising the quality-of-care people receive. Staff were encouraged to become champions in various areas such as end-of-life care, continence and psychological wellbeing among various others sharing best practice within the team. One staff member said, “We get offered extra training, [registered manager] is supportive about this.” Duties including completing audits of medication, equipment and other areas were shared between the team, staff spoke about feeling included and part of a team who work together and support each other. Comments included, “The team spirit is good and encouraging, when I was new other staff helped to teach me, and when I asked questions, they were patient.” And “I feel my opinion matters.” Cultural days such as the festival of light and Eid were celebrated and contributed toward promoting diversity helping to foster inclusion within the staff team.

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.

Quality assurance processes were in place, robust and effective at identifying issues in compliance within the service, meaning improvements could be made where needed. The registered manager carried out audits of systems in place including medication administration, health and safety and infection control, alongside audits of activities and peoples end of life care. These ensured that issues were picked up promptly and people’s care documents contained accurate effective guidance for staff to follow. Staff were also involved in daily checks around medication compliance. Champions within the home provided additional governance oversight when the registered manager was not onsite and had received training to ensure this was effective.

The registered manager used information in their systems to gain insights into patterns and trends, for example they had created trackers and matrixes for people’s Waterlow and must assessments to provide extra insights around the effectiveness of people’s support. Regular observations of staff competencies provided the registered manager the opportunity to observe how care was being delivered and improve staff performance. A staff member said, “[Registered manager] does checks to see if we are supporting people the right way.” Another said, “She’s very hot on following policy and gives us updates when things change.” The registered manager demonstrated their knowledge around being open and honest in reporting events within the care service under the duty of candour and knew their duty to notify CQC when needed. Staff said “[Registered manager] promotes the duty of candour and reminds us about how important it is to be honest when things go wrong.”

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.

The registered manager attended provider, GP and local authority forums to share best practice and learn about sector updates. They shared this information with the staff team to improve care delivery.

People received joined up care by staff working in partnership with healthcare professionals. A professional commented, “They call or email me for a care summary when a person is moving in, so they are up to date with current mediation, easing pressure of loved ones. Aiming for a smooth transfer into the home at what can be an emotional time for all.” Another comment was, “They have brilliant communication between the care home and GP practices.” When people needed to move between services, they were supported to do so with as little disturbance as possible, the registered manager was proactive about sharing information with other professionals and providers when needed and appropriate to promote good outcomes for people. Photographs and memory displays throughout the home added to the sense of community and provided opportunities for people to start discussions.

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 registered manager looked for ways to improve the effectiveness of how they support people. For example, improvements with medication by working with the Medicines Optimisation for Care Homes team (MOCH), who review the services practice and provide feedback to refine their process and raise quality of care delivery. Development was promoted in the staff team by the registered manager who knew the value of continual learning and the benefits it can bring to people receiving support. One professional said, “I often send [registered manager] any training programmes within the NHS that they may find interesting. As I know she is passionate about relevant training and professional development of her team.” To improve staff’s ability to respond to emergencies, such as in the event of a fire, the registered manager was upgrading their equipment to alert staff to a precise location rather than a zone meaning issues could be found faster should they happen. The Registered Manager actively supported sector-wide dementia care improvement through involvement in a research project and steering group for life story telling work. This initiative has developed training resources and best practice guidance to enhance outcomes for people living with dementia. Following project completion, the home plans to pilot the programme, train staff, and implement these resources.