Cotswolds Rise Residential 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 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 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. All staff had an induction when they started work which gave them information on the provider’s values and standards of working. Staff also had a set of ‘flash cards’ which had information on the provider’s care vision and values. We observed staff carried these on their person and there was a set available in the staff room.

A daily heads of department meeting was held to discuss activities at the home, complaints, incidents and accidents and people’s changing needs. This enabled staff to be involved in discussions about the management of the service and expected standards of care.

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.

When the service first opened, the provider had a commissioning manager in post who was experienced in opening new services. Since then, a permanent home manager had been appointed and at the time of this assessment had applied to be registered with CQC.

Feedback about the home manager was positive. Staff told us the home manager had an ‘open door’ policy, they were able to approach them at any time and share concerns. Staff said the home manager had already made improvements since starting at the service which had been necessary. For example, communication was improved with regular staff meetings being held.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had systems for staff to speak up if needed. There was a whistleblowing process and a confidential 24-hour free helpline staff could use. We saw there was information about speaking up at the service in the staff room. We also observed staff had a set of ‘flash cards’ on a key ring which included details on how to raise concerns.

Staff told us they were aware of opportunities to get in touch with the senior leadership team. For example, staff said the chief executive office held ‘drop in’ sessions on a Friday for staff to organise a meeting with them. This gave staff an opportunity to share any concerns or ideas of good practice.

The home manager told us they met with staff regularly and wanted to create a culture of learning and transparency. The regional manager visited regularly and made themselves available to any staff wanting to speak up or share ideas.

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 had access to a range of policies and procedures for equality, diversity and inclusion and also completed training as part of their induction.

The home manager told us the service asked staff during the interview process if they needed any adjustments to help them work. Where possible there was some flexibility to support staff. For example, 1 member of staff had their induction altered to enable them to learn in a more practical way. The home manager told us the staff team were all kind and supported each other. For example, for some staff English was not their first language. Other staff helped them with their written English when recording in people’s care records.

National and cultural celebrations were noted and gifts provided to staff where appropriate. The home manager said, “We have a zero tolerance to any discriminatory behaviour, I have not seen it here.” One member of staff told us, "I have not seen any discrimination. My first day I was overwhelmed with excitement. They [staff] welcomed me really well and I have been getting the support I need."

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.

There were a range of governance systems at the service which were effective in identifying areas for improvement and compliance. Audits were completed regularly and by different people. The home manager told us it was useful to have different staff reviewing systems at the service. This included staff from other services managed by the provider.

All actions identified for improvement were added to service improvement plans and monitored until completed. The provider had a team of central staff who helped to make sure governance was effective. This included a regional manager and a quality team. Whilst audits were identifying areas for improvement and compliance there were some shortfalls found during this assessment that had not been identified by the provider. For example, some medicines recording discrepancies and incorrect complaints response letters being used. The service took prompt action during this assessment to address shortfalls identified.

The home manager had a weekly email to update them on any changes to policy and procedures from the provider. This was shared with staff and action taken to make sure policies were read.

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.

People told us they were able to see healthcare professionals and other services when needed. During our assessment, we observed there was a multi-disciplinary meeting held with various stakeholders. The meeting was a first to bring various healthcare professionals together to review people’s needs.

Staff linked up with local groups and services to build relationships and establish the service in the community. For example, children from a local nursery had visited people which had been enjoyed by those involved. The provider had sponsored a local memory project which provided resources for people with dementia. Links had been made for services who supported people with other health conditions such as Parkinson’s disease.

Healthcare professionals feedback about the management of the service was that it was well-led. One professional told us, “Since [home manager] has been in post [they] have often approached me for more support when needed with residents and family and seems to be working hard at improving things at the home.”

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 recently set up an improvement and learning committee who met monthly. The committee included staff from all departments across the organisation. Meeting minutes were kept and recorded discussions regarding shared learning from individual incidents such as choking, CQC inspections and visits from environmental health officers. One of the aims of the committee was to identify trends and themes from all services to share learning.

The home manager shared examples of initiatives they were starting in the near future. For example, some staff had been enrolled on a specialist end of life training course. The course was for 5 months and the staff would be attending a local hospital as part of their learning. The home manager told us once trained the staff would share their learning with other staff at the service. The provider had sourced a virtual reality head set to enable people to engage in virtual 3D environments. It was hoped this would enable people to have unique experiences to improve wellbeing and minimise distress engaging in virtual communities and activities.