Croham Place

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.

This is the first assessment for this newly registered service. This key question has been rated 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 worked in partnership with the local authority and other agencies such as social workers, GPs and commissioners. This helped to ensure care and support was up to date with current best practice in relation to people’s specific needs.

The registered manager and management team worked in a collaborative way with other agencies. A range of care professionals described the excellent working relationships the staff had promoted for the benefit of people who used the service. Comments from professionals included, "Staff are very helpful and we work in a good co-ordinated way,” and “The managers encourage a joint working approach with doctors and community nurses. This all helps to deliver better outcomes for people."

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 the management team were capable, compassionate and inclusive leaders. The management team were suitably skilled and had experience and knowledge to manage the service well.
The management team were passionate about ensuing people and their staff were well supported through good leadership.

The management team were experienced and capable which provided a well-led service. The provider had clear systems and processes for their management team to follow and ensured they had oversight of the service. The provider had a management team who were in place to support the registered manager by completing audits of the service to further improve the care and support people receive.

The management team demonstrated throughout our assessment that they were capable, compassionate and inclusive leaders. For example, the team were honest, open, and transparent with the inspection team and where any risks might be identified, immediate action was taken because they understood and cared about the risk to people.

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

There was a warm and friendly culture within the service with a clear drive to provide high quality care. Comments we received from people and staff included, "The staff are really committed to providing a good service”; “The [registered] manager is very good, she is always here and takes an active role in helping us to tell her our thoughts.”

People and staff told us the management approach created an open and empowering culture in which they felt able to contribute their thoughts and suggestions. They said they were encouraged to participate in the development and improvement of the service people received and this provided them with much improved job satisfaction.

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 told us they were treated fairly and felt all staff had equal opportunities. The management team told us they had an open-door policy. There was always a manager visible within the care home to ensure staff could raise anything if needed.

The provider had clear processes and procedures in place to ensure they were working inline with the required legislation and ensured people’s and staff human rights were met. Staff were fairly recruited and treated. Staff had completed training in equality, diversity, and inclusion.

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 managers and staff understood their roles and responsibilities in relation to assessing, monitoring and managing the quality and safety of the care provided. The registered manager told us they carried out regular safety and quality monitoring checks on staff working practices in the home. A member of staff told us, “Managers carry out regular checks on our working practices. These checks are constructive and help us ensure we maintain high standards of care.”

Internal audits checked people’s records to see that tasks were completed and well-managed. They covered staff training and support, administering prescribed medicines, and dealing with complaints and safeguarding incidents.

The outcome of all the audits and checks were routinely analysed which helped the provider to identify issues and learn lessons about what they could do better. The managers understood their responsibilities in relation to their regulatory requirements around notifiable incidents. Timely notifications were made to the CQC.

People and relatives told us they were aware staff worked in partnership with other agencies to meet people’s needs. No one raised any concerns about access to other health services.

The management team told us they had a strong partnership with health professionals to ensure people’s needs were met such as the GP, district nursing team and pharmacist.

The provider had policies and procedures to ensure information was effectively shared with appropriate agencies. For example, with the local safeguarding team. The Local Authority had completed a visit, and the management team actioned all their recommendations and actions.

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 provider had effective procedures in place regarding reporting and learning from when things went wrong. The registered manager told us they carried out regular checks of the quality and safety of people's care. This included checks of the environment and equipment used for people's care and checks of medicines and care plans. Regular checks were made of any accidents. They were also carried out for people's health and nutritional status and any related incidents, such as weight loss, infection or skin sores. This helped to identify any trends or patterns to inform any changes that may be needed to improve people's care.

The service’s development plans included actions that came from these audits, quality assurance processes and feedback. All action points had a target completion date and identified the staff member responsible for them. We noted this system had been effective in driving improvements, such as improving the mealtime experience.