Deneholme Care Centre

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 newly registered 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 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.

Managers promoted a positive and person-centred culture within the service. People told us the atmosphere was welcoming, supportive and relaxed. Staff spoke positively about teamwork and described working together to provide consistent, high-quality support that reflected people’s individual needs, preferences and goals.

The management team were transparent and welcomed our feedback, which they were driven to address. The registered manager told us, “We had lots of work to do when we moved here. We are not quite there yet, but the care is very good and staff are dedicated.”

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.

A person said, “The manager and owner are both very approachable and they feel like family.” One relative said, “I know the management team really well and the home is really well run. I have no qualms about the level of care and leadership.” A healthcare professional said, “The staff are very caring and professional. I would have definitely have a relative living there.”

Staff told us managers were approachable and responsive. A staff member said, “[management] provide me with knowledge and training to help me in my role.”

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

Staff described an open and supportive culture where they felt able to raise concerns, seek advice and contribute ideas for improvement. A staff member said, “I can ask [management] at any time if I have any concerns.” Another said staff were "happy to talk" about areas for improvement and worked together to learn from feedback. Some staff felt communication between shifts could be improved, and leaders acknowledged this and were working to strengthen communication across the service.

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 spoke positively about teamwork and described a respectful and supportive working environment. They told us colleagues worked well together, communicated effectively and supported one another to meet people’s needs.

Staff had access to training on equality, diversity, inclusion and human rights, helping them promote inclusive practice and uphold people’s rights.

The provider had clear responsibilities, roles, systems of accountability and governance procedures in place. 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. However, some updates to paperwork were required.

Some paperwork required updating, including documents showing the service’s previous name and forms missing spaces for names or dates. Managers’ checks, kitchen audits and missing person records were also sometimes incomplete. The registered manager said they would make sure all documents were dated with names completed and would address this immediately. We found some care records needed updated, including ensuring documents were signed off by people or their representative to confirm they had been involved. Some policies needed to be reviewed, including being dated and signed.

The management team carried out a number of governance checks to monitor staff performance and ensure care processes were being followed. These were going to be reviewed.

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 described positive working relationships with local health professionals and community organisations. A healthcare professional said, “The staff do a great job in partnership with us.”

People were supported to maintain relationships with family and friends and to take part in community activities that were important to them. Leaders promoted partnership working and encouraged people to be active and included members of their local community. The provider had a day service attached to the care home, although it was not operating at the time of our assessment. The service had previously been used by people living at the home and members of the local community. Leaders told us they hoped to reopen the service once staffing arrangements were established.

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.

Staff described positive changes within the service, including improvements to communication, documentation and care planning. They told us training and development opportunities were available to help them build their skills and confidence in their roles. Leaders encouraged staff to share feedback and contribute ideas for improvement, supporting a culture of learning and continuous development. There was a clear commitment to driving improvements and enhancing outcomes and experiences for people using the service and the provider was using our feedback to support this. The registered manager said, “Your feedback was constructive and we are addressing the things you have raised and will work hard to make sure improvements are made.”