Telscombe Road

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 registered manager had installed an ethos at the service where people came first. Care and support needs along with people’s daily quality of life was at the forefront of everything. Staff were supported and there was a 24 hour, 7 day a week, call out process for managers, if support were needed either over the phone or in person. A safeguarding specialist was also on call for staff to contact if required. Staff were confident to use the whistleblowing process if needed, to ensure the ongoing safety of people. Contingency plans for the service were in place and were under constant review. In the event of service closure, people were to be moved to a sister home close by.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Accidents and incidents were reported and recorded by staff. Discussions were had at handover meetings daily and any learning was shared with all staff through updated care plans and then at fortnightly team meetings. Relatives were kept up to date with changes and learning developments from when incidents occur. A relative told us, “I call every two days but they will always update us in-between.” Another relative told us about an incident involving their loved one where the police were involved and there were potential risks to the person’s safety. As a result of the incident, risk assessments and policies were updated and there had been no repeat of the incident since. The registered manager told us, “Learning lessons are on the care manager’s weekly agenda.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had many opportunities to speak with the registered manager either as part of a group or team or one to one. Regular team meetings took place including extraordinary meetings that were called following incidents and accidents or other events of concern. Staff were supported during these meetings. Team meetings were held weekly and specialist guests were invited to alternate meetings to provide staff with updates and learning. Regular supervision meetings provided staff with a chance to speak to the registered manager and all staff we spoke with told us they were confident to raise issues, discuss successes and highlight areas of improvement and that they were listened to and action was taken.

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 service provided a Equality and Diversity Hub which was an information source where staff could access information and support about a range of issues. From the hub individual networks had been established to support staff for example, pride and race networks. Information and sign posting was available relating to disability forums and workplace adjustments. Staff religious and cultural needs were met by a service that respected and promoted difference. Diversity and equality policies were in place and staff told us that their working environment was inclusive and everyone felt comfortable in the workplace.

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. The service employed a quality improvement manger who was responsible for auditing. During their current absence the registered manager now oversaw all auditing processes. Within every care plan there sat a quality audit alongside the managers report. These are the monthly auditing documents that record all changes, updates and identify any trends of learning which are then shared with all staff. On a computer file these audits were updated using a quality tracker, completed by the registered manager monthly and overseen by area managers. The registered manager also oversaw monthly training data, cleaning schedules and medicine management.

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 had established positive and collaborative relationships with other health and social care professionals. Every fortnight a positive behaviour support practitioner attended team meetings to share updates and help resolve issues. Similar relationships existed with the speech and language team (SaLT), the resident college nurse and the occupational therapy team. All worked together to maximise the best outcomes for people living at the service. People were well established and known in the local community and at specific venues where they often visited. They were active working with voluntary groups, local music and sports clubs. The registered manager said, “We are passionate about the care provided here and getting them involved and getting them out there more. Fitting in and adapting and being inclusive.”

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 had fostered a learning approach in the workplace where accidents, incidents and any behavioural changes were openly discussed with staff, capturing any learning of best practice and identifying where things could be improved. Debriefing meetings were held and maintaining people’s safety and creating the best possible living space for people were paramount. A member of staff told us, “The focus is on people. If for any reason we can’t attend meetings, there is a register for us to sign to say we have read and understood the meeting minutes.” Another added, “Safeguarding is a standing agenda item at our team meetings.”