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. This enabled people to live independently for as long as possible in the comfort of their own homes.

Staff spoke positively about teamwork and described working together to provide consistent, high-quality support that reflected people’s individual needs, preferences and goals. Staff took part in the running of the service by contributing their views at supervision and staff meetings.

The management team were transparent and welcomed our feedback, which they were keen to address.

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.

Staff told us the registered manager led the service effectively and treated them with respect. They said they felt supported in their roles and were encouraged to contribute ideas to help develop and improve the service. Staff told us managers were approachable and responsive. A staff member said, “[Management team] are always open to listening to our opinions on our clients' needs.”

The management team demonstrated an understanding of their regulatory responsibilities and took appropriate action to address areas for improvement and strengthen the quality of care provided.

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

People and their relatives knew how to raise concerns or make a complaint and felt confident doing so. The provider had clear complaints policies and procedures in place, which explained the process for raising concerns.

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, “[Managers names] are always approachable if anything crops up.”

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 also 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. Although no impact to people, some updates to paperwork were required.

Some paperwork needed to be enhanced or updated, this included paperwork with the old service name on it and paperwork where no name or date space was included. 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 and risk assessments 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. Before the assessment had been completed the management team updated us that actions had been taken to address all of the issues we had raised regarding records. This was evidenced by examples sent to us. These updates needed to be embedded into regular practice.

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, especially those regarding medicines.

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.”

Managers promoted partnership working and encouraged people to be active and included members of their local community. The provider had a day service attached to their care home element of the service, although it was not operating at the time of our assessment. One person said, “I used to go to lunch at the care home every other Monday and Thursday for the day centre. Hope they start it back up again.” Managers 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.”