Greenfield View Care Home

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 Requires Improvement. This meant the management and leadership were inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

During this inspection, we identified a breach of regulation related to good governance.

This service scored 62 (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, human rights, diversity and inclusion, engagement, and understanding the challenges and needs of people and their communities.

The management team was supported by a staff team that shared their vision and values, working together to provide the best care possible. Both the management team and staff demonstrated positive values and commitment to continually driving improvements. A staff member said, “The provider’s values and aim are to create a family-type service, and I think they meet this; we are one big family.”

The provider explained their reason for opening the care home. They clearly had a drive and commitment to build trust, foster collaboration, and meaningfully impact people’s lives by being ethical, inclusive, and person-centred. Their experience of working with the local authority and seeking further guidance and support by employing an external consultant demonstrated this.

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.

Whilst the registered manager and provider had limited professional experience of managing a care service, they were compassionate and determined to develop their experience and be the best leaders they could be. We found the management team to be open and honest throughout the inspection process. Where shortfalls were identified, they took action to make immediate improvements.

Staff confirmed that the management team was visible, approachable, and supportive. They told us they felt listened to and valued. A staff member said, “I have worked in care for many years. I moved to the service a few months ago, and I’ve made some suggestions that the manager has welcomed.

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

Staff told us they felt well supported. Staff were enabled and encouraged to share any concerns and/or make suggestions during staff meetings, staff handovers, and supervision meetings. The registered manager told us they had an open-door policy and made themselves available to staff, this was confirmed by the staff.

Staff confirmed they had access to the provider’s whistleblowing policy and would not hesitate to use it. This policy allows employees to report suspected wrongdoing or illegal acts within an organisation in a protective and confidential manner.

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 provider had policies and procedures that protected staff’s human rights and working conditions. This included a Flexible Working policy. Staff could also opt out of the working directorate, enabling them to work additional hours if they wished, and the management team monitored this to ensure staff well-being. The staff rota considered staff’s shift and work pattern preferences.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We recognised the provider had worked with the local authority’s improvement team, had sought the support of an external consultant, and had a service improvement plan to further assist them in developing the service. However, we were concerned that the provider’s systems and processes had failed to identify all the shortfalls we identified during this inspection. This put people at increased risk of harm.

Staff roles, responsibilities, and accountability remained an area requiring ongoing development. Records from staff meetings confirmed that the registered manager had addressed these concerns multiple times throughout the year. However, staff continued to face challenges in effectively communicating key information and taking appropriate action.

This was evidenced in the ‘Effective’ key question of this report, where staff failed to hand over and act on an external healthcare professional's recommendation, putting a person at risk. This had not been identified by the registered manager or the provider’s oversight, systems and processes. After discussing this with the registered manager, they agreed that internal communication systems and processes required strengthening to support better oversight, coordination and responsiveness. Poor communication systems increased the risk of harm to people.

The provider’s systems and processes failed to identify four incidents that should have been reported to the Care Quality Commission in accordance with their regulatory responsibilities. These notifications play a vital role in how we monitor and assess service quality and safety. We raised this issue with the provider, who acknowledged this was poor oversight and demonstrated a commitment to learning from the experience and improving future reporting practices.

The provider’s systems and processes failed to fully identify the shortfalls found during this inspection, particularly in relation risk mitigation and ensuring staff had detailed and up-to-date guidance. This meant that risks to people's health, safety, and well-being were not always effectively assessed or managed, and staff lacked consistent, clear, and reliable information to support safe and appropriate care delivery.

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.

Feedback from external professionals was positive about partnership and collaboration. Two visiting professionals confirmed referrals for assessment and guidance were appropriate and made in a timely manner. They also confirmed that the recommendations they had made were followed.

The provider focused on continuous learning, innovation and improvement across the organisation and local system.

The provider had a service improvement plan that supported them in taking the required actions to further develop the service. Learning, innovation and improvements within the service were ongoing. New and improved systems and processes, however, needed further time to be fully embedded and sustained.