Melbourne House

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 service under the new provider. 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 82 (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.

There was a service improvement plan in place to track developments and ensure the required measures were taken to maintain the service to a high quality, safe standard. The provider, registered manager and staff team all had responsibility for ensuring these actions were completed. The provider had a clear business policy in place, with the provider representatives visiting regularly to carry out their own walk rounds and audits from these.

The registered manager showed a drive to improve the service and a passion to ensure the culture within the service was positive. Staff we spoke with felt supported and able to share their views on the shaping of the service.

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 showed knowledge and integrity and led the service by example. The skills they brought from their previous roles, showed in the ethos of the service. They explained how their approach to supporting people living with dementia and complex needs had become embedded at Melbourne House. They had fostered a positive culture, which was inclusive for all people, relatives and staff.

The registered manager spoke of their office being a ‘safe space’ for staff to come and debrief whenever they needed to. The registered manager fully respected their staff team, and described them as being like a small family, many of whom had been in post for a long time and supported each other both at work and in their private life. The registered manager understood the individual strengths of their team, explaining how each staff member had strong points of their character. The registered manager felt they all complemented each other like pieces of puzzle.

We saw evidence of a wide range of thank you cards and letters, which had been sent to the whole staff team. These acknowledged where the registered manager and staff team had gone ‘above and beyond’ in caring for people and providing support for their relatives.

Staff felt supported by their management team and were encouraged to support their peers. One staff member told us, “I feel the home is run really well and I am happy with the training and support provided for me.”

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

Staff felt able to raise concerns and give feedback and feel they had been listened to. The service had a robust freedom to speak up policy and procedure in place. Staff told us they felt confident in speaking up if needed.

The complaints process was clear and was displayed in the main entrance. The registered manager operated an open-door policy. People and their relatives told us they found the management team to be available and visible. No one we spoke with said they had ever had a need to complain, but felt confident the registered manager would listen to them and respond. One relative told us, “I have never needed to complain about anything.”

We saw the registered manager had reviewed and analysed themes and trends of any complaints or concerns received. The registered manager could demonstrate how they would prevent similar issues from happening again, as they learned lessons from previous outcomes.

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 service celebrated and championed their diverse workforce. The provider employed staff from the local area as well as from overseas. The staff team were from varied backgrounds and cultures, and this was reflected in the skills and experience they brought to their roles.

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.

Information was used by the management team effectively to monitor and improve the quality of care. For example, accident analysis records showed a breakdown of time of day, location, why the incident occurred, and any actions taken. There was detailed information recorded on any lessons learned. The safeguarding log showed evidence of analysis, lessons being learned and of these being shared promptly with the staff team. This information included any contributing factors and actions taken.

The management team held regular operations meetings, following which, required actions were detailed and allocated amongst the team. The management team ensured these actions were incorporated into the overall service improvement plan.

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.

The service had positive relationships with the covering GP practice and external health and social care teams. We saw referrals had been made promptly where a need had been identified, or a person’s needs had changed. For example, following a fall with an injury, or where a change in a person’s cognition had been identified.

The provider always focused on continuous learning, innovation and improvement across the organisation and local system. They always 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 registered manager was proud of the research the service was involved in. They explained the service was a partner in a project looking at the impact on falls, continence and sleep hygiene, by the reducing of caffeine intake in drinks. We saw posters displayed, explaining this approach, and staff were fully engaged in documenting their observations and sharing these with the project lead. The service worked with the local falls specialist, on a research project looking at innovative ways to reduce falls and the long-term impact of falls related injuries. The registered manager explained how they had already seen positive outcomes for some people in relation to improved sleep patterns. The registered manager was looking at how this could be implemented more widely into practice across the service.

The home was supported by a training and compliance officer and the nominated individual, who carried out regular announced and unannounced visits and produced reports to support the registered manager. The registered manager spoke of feeling well supported by the provider team and of using their feedback to drive improvement. The registered manager also attended meetings with other registered managers within the provider group, allowing for peer support and for the sharing of good practice.