Thorn Springs

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 inspection we rated this key question requires improvement. At this inspection, 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.

At our last inspection the provider was in breach of the legal regulation in relation to good governance. Improvements were found at this inspection,and the provider was no longer in breach of this regulation.

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 registered manager and management team 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 understood their main role was to support people to have the best experiences possible. The registered manager and management team had worked hard to create a positive culture at the service. People were happy and relaxed being supported by staff. Feedback from people, relatives and professionals about the service was positive and the service was described as having a friendly atmosphere. Staff told us they felt well supported and were committed to trying their best to give people the best experiences possible. One person said, ‘‘It is lovely here. I cannot fault it and think all the staff do a great job.’’ A relative told us, ‘‘The service is a welcoming and relaxed place day and night. No matter when we visit, we have no concerns.’’

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support. They did so with integrity, openness, and honesty. The registered manager and management team were a very active presence at the service, spending time with people and staff. This meant they were aware of any support that was needed in real time, and that people and staff saw them as a reliable part of the team. The management team listened and took feedback seriously. As a result, people and the staff team felt included in discussions about the running of the service. Staff felt very well supported by the management team. People and relatives told us the management team were kind and caring. One person said, ‘‘The service is very well run, and [registered manager] is lovely and always ready with a listening ear.’’ A relative told us, ‘‘The service really is good, and I think some of this comes down to the [management team] who are almost as much a part of the staff team as [staff]. They really do their best.’’

The provider fostered a culture where people felt they could speak up and their voice would be heard. Staff knew how to speak up and raise concerns and told us they would feel comfortable doing this. People and relatives knew what to do if they needed to make a complaint and were assured that these would be investigated and taken seriously. There was a detailed whistleblowing and speaking up policy in place at the service. The registered manager kept a record of concerns and made sure people were responded to with a resolution and any changes that would be made as a result of the concern being raised. One person said, ‘‘We can always speak to someone if we are not happy and [staff] change things quickly.’’ A relative told us, ‘‘I have not had a reason to make a complaint but feel utterly confident that if I did it would be taken seriously.’’

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. Staff felt well supported and told us they could approach the management team to have discussions about any help they needed in their job roles. The provider supported their equality and wellbeing by offering preferred working patterns and discussing their job roles with them regularly. The provider’s recruitment process was fair and equitable.

The provider and registered manager 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. Audits and governance measures at the service were effective and the management team had a good oversight of risk and the quality of people’s care and support. These covered areas such as health and safety, improvements to the service, people’s experiences and staff training and supervision. Where areas of improvement were identified appropriate actions were put in place. Plans were in place to help ensure the long-term sustainability of the service.

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 saw health professionals if this was needed. Visiting professionals were positive about the staff team and how they worked with them. The management team worked well with partners such as the local authority. Staff supported people to places of interest in the local community such as museums and garden centres. Staff encouraged and supported people to be a part of the local community at the service by spending time with each other in communal areas and taking part in shared interests and pastimes. One person said, ‘‘I like to stay in my room, but the staff will come and let me know what is going on. Sometimes I choose to go and sit with my friends.’’ A relative told us, ‘‘There is a lot going on at the service and [family member] is definitely more sociable now.’’

The provider and registered manager 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. The management team had improvement plans in place based on findings from internal and external audits. Actions on improvement plans were monitored to help make sure improvements were benefiting people using the service. Staff told us they were involved in discussions and meetings about the service and their feedback about how to improve the service was listened to and taken seriously. There were some minor areas for improvement identified at this inspection in areas such as mealtime experiences and how people were supported to understand information. Immediate action was taken by the management team to start rectifying these and we were assured improvements would be made. The registered manager and staff team had made improvements at the service since our last inspection. People were happy with their support and relatives told us they felt the service had and continued to improve. One person said, ‘‘Every day is a good day here.’’ A relative told us, ‘‘[Registered manager] is really invested at the service and wants things to keep improving. [Family member] is having a great time living at the service.’’