Greenacre Park

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 Requires Improvement. 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.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

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 now had a shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Significant improvements were observed and evidenced at this assessment when compared to our previous one. The current manager, who had been in post for a sustained period, supported by the regional director, had made notable improvements to the culture at the service.

They demonstrated a positive approach and ongoing commitment to continuously develop the service to ensure people remained at the centre of what they did. They told us how proud they were of the progress made and how their FIRST (Fun, Integrity, Responsive, Success Teamwork) values were being embedded to achieve their mission of ‘Everyday Better’.

Staff were observed to work well as a team and were knowledgeable and knew people well. The atmosphere in the service was warm, relaxed and welcoming. One staff member told us, “There were significant issues here last time you (CQC) came. The home is a long way forward from that and positive changes have been made. Nothing is ever perfect; it’s the nature of what we do but it is very different here now.”

Relatives also spoke positively about improvements made to the service. One relative said, “They seem to be a big improvement from the previous management team. I think they are more approachable, feel more caring and there seems to be more systems in place. The current manager seems very nice and caring.” Another said, “We know the manager and the management team pretty well.”

We identified 2 areas for the provider to strengthen following mixed feedback we received in relation to general communication with relatives and their involvement in care plan reviews.

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 regional director was open and honest during the assessment about the failings at the previous one. They told us, “We cannot disagree with your previous findings and have worked hard to remedy those over the past 12 months. We feel we have made significant progress and have now addressed those shortfalls.” They added, confirmed by the provider, “I will continue to have a frequent presence at the service to ensure the service remains on a stable footing and our progress does not regress.”

Managers were knowledgeable about their responsibilities regarding their adherence to the Health and Social Care Act 2014. They knew the types of significant events which they were required to notify to CQC, and records showed the service had informed CQC through the appropriate notifications process as required.

We received positive feedback from staff regarding the support they received from the management team. One staff member told us, “Since [manager and regional director] have come, things have improved. Managers are available and it’s always nice when senior managers are here, they take the time to speak with people who live here, and they have got to know them too."

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

Managers were candid and open about lessons learnt. They understood duty of candour and their responsibilities. The management team were visible and had an open-door policy to ensure people, relatives and staff could provide feedback or raise concerns.

Staff understood their responsibilities to report any concerns and ensure those in their care were treated safely and compassionately. Staff had been trained in safeguarding and whistleblowing and were confident which processes to follow and who they needed to report any concerns to including external agencies.

Staff received opportunities via a survey to provide feedback about working at the service including what’s working well and any concerns. Actions taken by managers in response to feedback were openly displayed.

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 an equality, diversity and inclusion policy. 

The provider had a commitment to develop and promote staff within the service. Members of staff told us about how they had progressed to more senior roles within the service and felt managers invested in them.

Daily ‘huddles’ were in place between the staff and regular staff meetings were held with each of the staffing groups to share their views, experiences and make suggestions. Meetings were recorded minutes to ensure that all staff had access to the information they needed.

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.

At our last assessment we found the provider needed to make improvements to their governance systems and quality assurance processes. At this assessment we found notable improvements had been made.

These improvements had been embedded over the previous 6 months. To sustain these improvements we received assurances from senior leaders about how the service would be closely monitored to maintain and sustain them. This assured us the service would continue to have sufficient and robust oversight.

There was a comprehensive system of audits and quality assurance covering all aspects of the service. Senior managers had oversight of the service from in person visits and remotely. This ensured the service was continually monitored to ensure sustainability could be maintained.

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.

Positive relationships and a joined-up approach were evident with healthcare agencies, professionals and other stakeholders. We spoke with a local authority representative who was complimentary on how the service had worked with them during their quality assurance improvement plan. This engagement had brought about real change and improvement to quality and performance at the service.

Staff and leaders ensured people received holistic continuity of care and support which met their needs.

Records showed that staff had contacted a range of health and social care professionals for people as their needs changed and specialist support was needed to maintain their well-being.

The provider had focused on driving learning and improvement throughout the service following our previous assessment. The provider worked in collaboration with other stakeholders and were receptive to the support afforded to them in an open and transparent way.

Stakeholders provided us with positive feedback of their involvement over a sustained period. Our observations, feedback we received and evidence we reviewed, assured us the provider had taken seriously the concerns we identified at our previous assessment. This meant the quality of life and people’s experience had overall improved. The provider told us they were committed to sustaining the improvements made.

Staff were supported with their personal development and to undertake additional training to improve their skills and knowledge. There was a rolling programme of improvement which was continually updated. Records confirmed improvements made and those outstanding with timescales attached. The regional director accepted our observations that the internal décor required changes to make it more person centred. This action was subsequently recorded in the improvement plan.