Abbey Grange 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.

At our last assessment we rated this key question inadequate. 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 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 service 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 were extremely positive about the changes and the support provided by the management team. One staff member told us, “There have been massive changes since the last inspection (assessment), managers have embedded a lot of good practices, everyone is allocated their roles and champion responsibilities which makes sure everything runs smoothly. Staff are now more involved in the running of the service, and we have monthly meetings and chat to staff about what is going right and what we can improve.”

Staff were seen engaging positively with the management team and it was clear good working relationship were key in moving the service forward. The nominated individual and deputy manager discussed the significant amount of work that had taken place since our last assessment. They told us they had sourced an external company to drive improvements and introduce more detailed governance and oversight. The nominated individual said they would continue to work with this company to continue to improve.

Records we revied confirmed staff meetings were being held regularly. Agendas were recorded and minutes from topics discussed were seen. The nominated individual was completing a Local Authority action plan; this was rated in order of their priority to complete. Records confirmed this was reviewed and updated as changes occurred.

The service 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 they were positive about the visibility of the leadership and management of the service. They said the nominated individual was present daily and was accessible to all of the staff. Comments included, “[Nominated individual] is here every day; [person] is very good. [Registered manager] hasn’t been here for weeks. Any concerns the [nominated individual] rectifies things straight away and solves any issues” and, “The managers are very supportive. [Registered manager] has been off for a while, but [deputy manager] and [nominated individual] are here, not at weekends, but we can contact them.” It was clear good relationships had been established between the staff team, people and relatives and the management during our assessment.

It was clear that the knowledge and understanding of the nominated individual and senior team had improved since our last assessment. Records in relation to the governance and oversight of the service confirmed the actions taken by them to drive improvements.

Records we reviewed confirmed team meetings were taking place and minutes from these included the dates and topics that had been discussed. These demonstrated that staff were involved and recorded their feedback from meetings. Senior meetings were taking place with topics recorded, these had been shared with the staff team to ensure they were kept up to date.

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

People and staff were supported to provide feedback, information about how to raise concerns was available in the service user guide and there was a comments and suggestion box to obtain feedback about the service. Positive feedback was seen in thank you cards, and regular surveys and questionnaires were completed by staff, professionals and visitors. These included positive feedback from them.

Supervisions were regular and ongoing with the staff views recorded. Staff told us they were aware of freedom to speak up and had provided feedback about their views. One said, “I know about freedom to speak up, I will always report concerns, I fill in surveys regularly and send them off. We always have staff meetings and flash meetings.” Feedback that staff were valued by the management was seen. Staff were awarded with bonuses celebrating their successes. A range of up-to-date policies and procedures were in place to support in their roles as well as their well-being and diverse needs.

The service 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 were complimentary about the management team, felt they were engaged and informed and were happy in their role. They told us, “We are treated fairly, managers listen to me” and, “We always discuss lessons learnt in handovers and meetings. Every staff member has an allocated topic they champion in and lead on that by doing audits, checks and they update all of the staff.” We saw the names and the roles of champions on display in communal areas and records of minutes from team meetings that included the topics discussed. Training records confirmed staff were up to date and supervisions were undertaken, this would support staff to discuss their diverse needs.

We saw some records that confirmed staff were supported with their wellbeing and the management supported their diverse needs. One person was seen doing a high number of hours in a week, the nominated individual introduced a 48 hour opt out agreement to ensure their hours and had been discussed and agreed with them

Staff had access to up-to-date policies and guidance, and these were updated by the company as required. The management team told us they were able to check when staff had accessed the policies and confirmation that they had read and understood. Most staff knew where policies were located.

The service 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 nominated individual demonstrated their understanding of the service and the changes they had made to improve. Significant improvements had been made to the audit and governance system. Regular audits were being undertaken and ongoing, these included the findings from these and evidence that they had been reviewed by the nominated individual. Senior audits were now being completed and had been done recently, these demonstrated that oversight and monitoring was ongoing.

The nominated individual told us they had submitted an application to the Care Quality Commission to register as registered manager along with the current registered manager to support them in their role as they had had a period of sickness. The nominated individual was in the service daily. There was also a new deputy manager in post that was supporting the nominated individual with the governance and oversight. A sustainability plan was being developed that would put measures in place to consider the environment.

The provider had a business contingency plan that would support the service in the event of an emergency. Their statement of purpose had been updated and the nominated individual told us they had submitted a notification to the Care Quality Commission to add service user bands that reflected the people living there. We discussed the importance of ensuring the services ratings was on display in the communal areas, the nominated individual gave assurance that this would be on display at all times, we saw this was displayed in the entrance on the days of the assessment.

There was a clear management and staff structure in place and staff understood their roles and responsibilities. Staff knew what was expected of them in their roles.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and mostly collaborated for improvement.

There was evidence of the involvement of professionals. People were accessing the community, undertaking activities of their choosing. A staff member told us, “People get out and about more, people go into the community for lunch, shopping or haircuts.” But they told us no church or community groups visited Abbey Grange care home.

People and relatives were overwhelmingly positive about the improvements since our last assessment and the upmost praise for the management team. A relative said, “From the décor, the flooring, everything in the home has had a much-needed revamp. (This is all down to the good work and dedication of (The nominated individual) and the staff team. Others said, “I hope they get out of special measures so they can attract more residents soon” and, “If I needed a home to go to later in life I would be happy to live here.”

The staff and the management team told us a range of professionals were involved in people’s care and support. We saw professionals visiting the service. Feedback from people and relatives confirmed professionals were mostly engaged and involved.

The service 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.

Significant improvements were noted at this assessment and the nominated individual discussed what they had done since the last assessment to improve. They were continuing to work on an action plan developed from assessments by the local authority. Most professionals talked about the improvements in the service. Notifications were being submitted as required to the Care Quality Commission.

Staff said the improvements were ongoing and they had seen a change. One told us, “It is very well managed, everything has changed here, we really give person-centred care now, people and staff are more involved in everything. Staff are now key workers which means we promote people’s rights and independence, and we can spend more time with them.”

Staff had undertaken relevant training to support them and extra training had been undertaken by the staff specific to their champion roles. Supervisions and spot checks had been undertaken and there was information and guidance to support staff knowledge seen.