Dickley Court

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service and notifying CQC of incidents and events at the service.

This service scored 62 (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.

Information about the vision, strategy and culture was available around the service for people, relatives, visitors and staff. The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The provider’s short breaks website stated, ‘We are passionate that like everything else we do, we get things right for and with people. To do so we find meaningful ways of evaluating the quality of service including seeking feedback following every visit from families and individuals, undertaking spot management visits, observations, surveys and participating as necessary in care reviews. In the light of these we make necessary changes.’ We observed this was put into practice in relation to evaluating the service and gaining feedback when we carried out the assessment.

Staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “There is a good culture”, “The whole staff team are lovely, we support each other” and “We do have weekly meetings and teams calls. We get information and we always have a handover.” A health and social care professional said, “It appears to be well managed, staff have a positive attitude to their job and role, and they endeavour to do their best which I am delighted to see when I visit.”

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 management team knew people well and were passionate about making sure people received good quality care. There was a clear management structure in place with the registered manager and an assistant team leader. The registered manager attended regular management meetings. The service also had care staff to provide care and support. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the nominated individual for the provider. The nominated individual is responsible for supervising the management of the service on behalf of the provider. The registered manager told us they were well supported by the provider. Staff told us the registered manager was supportive and approachable and were confident in reporting any concerns.

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

Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to.

Complaints processes were available. The service had received no complaints. Relatives told us, “We have never had any complaints, it is so good for her, and she gets to be with younger people and I get a break. They always give me a report every evening. She is always happy to go” and “[Registered manager] is really open and honest and listens to us.”

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 told us they felt well supported and they felt communication was good. The registered manager told us there was flexible working, around childcare and religious needs. There was a menopause policy and support available for staff who were experiencing menopause. They said, “We have an internal counselling service, we are looking at mental health champions to support staff. Staff can have advances of money on request. This was utilised a lot in lockdown.” Staff had annual appraisals as well as pay recognition based on performance. The registered manager also shared that the provider arranged provider wide parties and events for staff and for people using the service.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider had systems in place to check the quality of the service. Audits had been carried out. There were audits of people’s experience, documentation, staffing, medicines, incidents and accidents, health and safety, fire, PPE, COSHH (Control of Substances Hazardous to Health). The audits were not always robust enough to highlight and manage shortfalls and areas for improvement in the service. For example, health and safety audits of the service had failed to identify risks with the environment such as missing window restrictors, burns risks from exposure to hot pipes and surfaces as well as risks with water temperatures, as well as the potential risks to people in relation to their care and support needs.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were not always assured that incidents had been appropriately reported. CQC had not been notified of a safeguarding incident which had occurred and DoLS authorisations.

Where audits had identified actions, actions had been recorded and the management team had signed off items that had been addressed.

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 management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities and the local authority. A healthcare professional told us the service did well at, “Accepting support from myself and acting on recommendations.”

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 registered manager told us they had reviewed the feedback we gave them as part of the onsite and offsite assessment process and valued this. They were using the feedback to make improvements to the service and to put systems in place to embed the changes. Areas discussed at the assessment site visit were added to the action plan for the organisation in a timely manner and the registered manager updated CQC on the progress of these actions.