The Thatched 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.
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.

At the previous inspection we found records were not always accurate and complete, including for staff employed by the provider. This was a breach of regulations. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

At the previous inspection we found systems did not support the continuous evaluation and improvement of the service. This was a breach of regulations. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 71 (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. The provider was passionate about care at the home and explained to us how they wanted the home to be a positive and cheerful place. They told us they expected this from staff. Staff were well supported as the registered manager believed that staff work better when they are happy and confident. Staff told us they worked well as a team and knew people well. We saw people and relatives interacting with the staff and registered manager during our visit and people were included and engaged in conversation as a matter of course.

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 did not always have the skills, knowledge, experience to lead effectively, however they managed the home with integrity, openness and honesty.

The provider supported the registered manager in their role. The registered manager was competent and caring; however they lacked some technical skills. The provider information return had not been sent to the Care Quality Commission as requested.. The home continued to use paper notes, care plan print outs alongside electronic-records, and paper records for staff training. Risks associated with not using technology or using it alongside paper records meant there was potential for incomplete or inaccurate information, increased risk of errors, and reduced efficiency in care delivery. The provider and registered manager were working to improve their knowledge and the use of technology to reduce the amount of paper used at the home.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff and people at the home had good relationships with the senior team. Staff were confident to speak up because they knew the provider was open to ideas to improve care. Relatives and people at the home were happy to talk to the registered manager because they trusted them to act on concerns raised.

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 employed a mixture of local and overseas staff. Staff worked well together and the provider supported them to work to the best of their ability. A member of staff told us, “The manager always helps if we struggle”. The provider told us staff were matched to work shifts so staff needing to improve their English were supported by staff who spoke English well. The provider ensured overseas staff were taught about British laws to protect them, and to ensure they could give safe, appropriate care.

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. The provider supported the registered manager in the management of the home. Audits were carried out and recorded to ensure continuing good care. To ensure good oversight of care the managers worked alternate shifts. Staff were confident in their roles and happy to speak to senior staff if they needed extra assistance with anything. People’s care plans and support needs were monitored and recorded, staff shared information to ensure safe continuation of care in ways people wanted.

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. Staff understood the need to work with other healthcare professionals. We spoke with a visiting healthcare professional who was very positive about the service and the staff at the home. They told us, “There seem to be enough staff and they are helpful. I have never needed to raise a concern.”

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 was keen to learn and improve the service. The home had been refurbished following a previous inspection, and enhancements made to improve people’s quality of life. For example, the provider had added pictorial signs to bathrooms. The registered manager had also streamlined and improved the staff recruitment procedures. The registered manager explained how they carried out daily inspections of the home and encouraged staff to suggest changes and improvements to them. An ‘incident and accident book’ was used to record events and actions along with learning for staff. The provider had plans to redesign the home to ensure the space was used effectively. The provider had purchased conversation prompt cards for staff, to give them ideas of things to talk to people living with dementia about; things like “What was your school like?” The provider told us “Staff can learn about people by chatting to them. It’s a simple activity people enjoy.”