Blythgate Manor

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 inspection for this service. This key question has been rated good. This meant the service management and leadership were consistent. Leaders and the culture they created supported the delivery of high-quality, person-centred care.

This service scored 86 (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. People and professionals said the service encouraged people to regain or maintain their independence, achieve exceptional outcomes and extend their abilities. There was a cycle of learning, improving and always striving for the best care and support for people's needs so could be met effectively. The provider had employed a clinical compliance manager to work across their homes to promote good practice, share learning, clinical support and peer support to help ensure people received quality care and enhance their well-being. Part of the role was also to provide mentorship and support to a range of roles, including clinical supervisions. The provider acknowledged that the workplace could be stressful and introduced resilience-based clinical supervision for nursing staff, along with a similar supervision framework for non-nursing staff. These sessions allowed staff to reflect on their personal reactions and coping strategies, helping them understand and manage emotional responses to work-related stress and maintain their mental well-being. This resulted in promoting the confidence, good days at work and leadership amongst the staff team. A staff member commented, “I get very good support and access to training.”

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. The registered manager had worked to boost staff morale and strengthen teamwork. Several staff and people commented about the improvements to the service since the change in ownership and registered manager. Staff member’s comments included, “Management are supportive”, “The manager is good” and “Communication has improved, it is clear what is expected.” A professional commented, “The staff deal with some very challenging, multimorbidity patients who are often very frail and nearing end of life. I have noted that since the change of management, there has been more support for the nurses and staff on the floor.” Staff had the opportunity to progress and follow management training. A monthly deputy manager meeting took place across the provider’s services to support staff in their role with not only advice, but practical support in the form of sharing ideas, initiatives and good practice. As a result of these meetings deputies had the opportunity to network, gain confidence in leadership and progress in management. Staff had the opportunity to develop and received leadership training to help them in their management roles. A staff member reflected, “I have been promoted, it is a great achievement. I have also started a management course.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a clear whistle blowing policy. Staff could raise concerns, and written information was available of how to do this. Staff meetings took place, and staff had the opportunity to share comments and give feedback. People were informed of the complaints procedure when they started to use the service and at meetings.

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 able to ask for reasonable adjustments to be made to their working patterns for specific needs, for example, to incorporate family commitments.

The provider ensured the governance was effective and robust, including the monitoring of the quality-of-service provision. The service had clear responsibilities, roles, systems of accountability and 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. Regular audits and checks were carried out in the main areas of the service, such as, around care records, health and safety and staff practice. Audits showed action was taken where areas of improvement were identified.

Staff at 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 collaborated for improvement. Management attended local provider forums to share good practice. The provider and registered manager had grown their networks with partnership agencies and charities. They took a pro-active and practical approach to involving themselves in local and national projects and initiatives such as the Alzheimer’s Society, Mind Active and hosting McMillan fund raising events which benefited people and the community. Staff helped veterans living at the home to access and enjoy visits from the local Veterans in Care charity. There were links with local churches with visits for people who still practiced their faith. Staff also arranged cultural celebration days. The home was involved in intergenerational projects with a local school which benefited the children and also people living at the home. A range of care professionals described the very positive working relationships the staff had promoted for the benefit of people who used the service. The management team were positive about their links with local partners and health and social care teams. A professional commented, “Blythgate staff are always willing to accept input from our service and ensure that staff are able to attend assessments, formulations and training sessions where these are necessary.”

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. There was evidence of changes that had been made to the service to make improvements and to address checks and audits outcomes and in response to people and staff feedback. External quality assurance arrangements were in place to monitor the internal governance systems.