Bishops Corner

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.

This service scored 68 (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.

Staff spoke to us about the vision and culture of the service. Staff said that the management team were approachable, listened, and that they feel well supported. Staff told us how everyone worked together to give people a structured and happy place to live the life they want and achieve their full potential.

Staff supported people’s (and staffs’) cultural and spiritual needs. People were treated equally, and their individual needs were met in line with their preferences. The management team were knowledgeable and worked alongside staff to support and promote good practice.
Feedback from staff was positive when we spoke with them, many had worked in the service for several years and were committed to the people they support. They continually promoted people’s involvement, choices and independence. The service aimed to give people consistently good care and staff worked together to try and achieve this. Individual staff supervision and group team meetings were used by the provider to remind staff about their organisations underlying core values and principles.

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.

Staff told us that management team were approachable, knowledgeable and listened. They said, “We did go through a bit of a difficult time a few years ago, but we have really worked hard to get better and back on track. We have a new manager, who really seems pro-active and a good leader, with lots of knowledge.”

We were told that the focus of the service was to ensure people were safe and happy, and that any learning was taken forward positively. The senior management team was committed to improvement and was open and transparent regarding the improvements made and those that were on going. The registered manager shared the improvement plan commenced since he joined the organisation late 2025.

There were systems and processes in place to support staff development and progression within their roles. Supervisions had been sporadic in 2025 due to management changes, but all staff were back to regular supervisions now.

Staff talked of how they were supported to gain qualifications and to consider extending their role, senior care staff were supported to be become medicine givers and received support and training. Regular supervisions, spot checks, competencies and values-based supervisions took place. The provider’s senior management visited the home regularly and provided support and supervision to the registered manager, who confirmed they attended organisational manager meetings which enabled learning across the organisation to be shared, and relevant lessons learnt implemented within the home. The provider supported staff to attend external training, conferences and meet with other providers and managers to network through various forums

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

Staff knew how to raise concerns outside the organisation if they were concerned appropriate action was not being taken. Staff were confident any issues raised would be addressed immediately. Staff were able to discuss the whistle-blowing policy and told us they would report any concerns to the senior staff on duty or the management team. The registered manager told us staff were able to contact managers from other services for guidance and support at any time.

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 home was proud to be inclusive and supported both staff and people that used the service. The staff team was diverse, and everyone was respectful of each other.

The provider had procedures in place to promote staff well-being and worked to provide flexible working conditions if required.The management team met during the inspection told us they encouraged and supported open communication and there was an open-door policy. There was a formal recruitment process and equality, diversity and inclusion policy in place to guide equitable and fair recruitment and selection procedures. Staff were encouraged to undertake training in equality and diversity.

Quality assurance systems were in place; however, these had not always been used effectively to identify the improvements needed and consistently drive improvements to the service. The management team had worked hard over the past few months to introduce robust oversight and effective governance at the service which had lapsed. There were still areas to improve, and this was acknowledged by the registered manager. For example, medicine management, improving care plans and risk assessments, daily log documenting, and introducing a more active social life for people to reach their full potential. Improvements were also needed to ensure the home was adequately clean, comfortable and welcoming. These were fully discussed during the assessment process. The registered manager had identified that care plans and risk assessments needed improving and this was already being undertaken. Immediate improvements were made regarding medicine management, and a full medicine audit undertaken, and a deep clean of certain areas was completed. From talking to staff, there was a lot of knowledge known about people, but this had not been transferred into people’s care and support plans, a new member of staff would not know the history or some of the risks.

Staff told us about their duties and responsibilities; they told us how they managed risk and reported concerns to management. Managers and staff understood their roles, and were clear about quality performance, risks and regulatory requirements. There were checks and audits in place to monitor quality and safety. Action was taken when audits identified areas for improvement. We have received actions plans/improvement plans which have been updated during the assessment process.

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 consistently supported across a range of different services and agencies. There were established systems in place to liaise with other professionals. One professional said, “Overall the communication is good, I enjoy working with them, they are good with the people they support.” The registered provider told us that within the organisation there were regular meetings and training opportunities that staff and leaders attended. These were opportunities to share knowledge and learning and consider future developments.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Because of the recent lack of robust auditing and quality monitoring there was no record of learning lessons from when things go wrong. For example, out of date people profiles in MAR, accidents and incidents whilst recorded and discussed at handover or daily meetings had no root cause analysis undertaken to prevent a re-occurrence.

The current care plan system was not fully embedded into everyday use at this time. The registered manager had identified areas to improve and was working his way through the care plans and risk assessment to ensure they were written and reviewed with people and families and user friendly.