Bassett 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.

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.

Staff told us the service worked in ways that promoted people’s independence and maintained their dignity and privacy. Staff said the registered manager put these values into practice in the way they managed the service.

The registered manager told us the provider values were shared with staff during induction and then when needed in refresher training. The management team supported staff to discuss the service’s shared values at meetings. Staff were frequently supported to reflect on the expectations of providing good person-centred care.

The provider showed us their work on a new website for the service. The provider’s values were included on the website as information for anyone visiting online.

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 was open and approachable. Comments from staff included, “She listens and tries her best to resolve any issue. She is a good leader” and “She is a good manager and fair to everyone. She sets the rules and follows this through to make sure staff do it.”

The registered manager had been in post at the service for many years and was supported by an experienced deputy and team of nursing staff. There was a clear structure in place, and everyone was aware of their own responsibilities. The registered manager had support from the provider, their management team and external forums for other registered managers.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. The provider had a whistleblowing policy and process for staff to use if they wanted to share concerns. Staff were aware of systems for them to raise concerns anonymously if they needed to. Staff told us they were able to raise concerns with the registered manager directly and were confident they would be listened to.

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 employed a diverse range of staff with different ethnicities. The registered manager told us everyone was welcome at the service, and they were proud of their diverse workforce. Any national celebrations from diverse cultures had been promoted, and staff were encouraged to celebrate if they wished. Staff had been encouraged to share information about their own cultures with people and other staff.

The provider had a range of policies and procedures on equality, diversity and inclusion. Staff were provided with training on this during their induction.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Whilst improvement to governance systems had taken place, further improvement was required. The provider governance systems had not identified records relating to risk analysis and food hygiene were not completed consistently. The registered manager told us they were taking action to address these shortfalls. There were systems of governance which monitored safety, however, there was a reliance on the registered manager to produce and analyse the results. This meant in their absence locating reports and analysis was not always possible. The service was moving all care monitoring and recording onto an electronic system which would enable more people to have oversight of data.

Leaders were all responsible for various checks and audits to monitor quality and safety. We found audits were being completed for areas such as medicines, infection prevention and control and the environment. Any actions identified were monitored by the registered manager to make sure they were completed in a timely way.

The provider visited the service regularly and had oversight of the refurbishment work being completed. They supported the management by liaising with contractors to keep disruption to a minimum.

Statutory notifications had been submitted to CQC when needed. The providers policies and procedures had been reviewed prior to this inspection.

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 worked closely with various healthcare professionals to make sure people’s health needs were met. Feedback from professionals about the service and the staff approach was very positive. Comments included, “The communication with the nursing team is great, they are always more than happy to help if I have any questions and the home managers and care coordinator is always happy to help and book in assessments as needed. The approach of the care staff and how the service is managed is excellent.”

The registered manager was on the board of a local provider forum. This was an organisation aimed at supporting care providers in the local area. This enabled the registered manager to keep in touch with other services, providers and external stakeholders and share knowledge. There were regular online and face to face meetings, training and information events.

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 service had a team of registered nurses who kept up to date with learning and development. They encouraged care staff and other staff to develop skills and knowledge and to learn from colleagues and external stakeholders.

The management team encouraged staff to share any ideas for changes to the current ways of working that may support improvement. The service was migrating all their care records onto an electronic system which would help staff to have better access to up to date information. There was also a plan to move medicines records onto an electronic system once the care records were fully operational.