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.

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.

The provider and management team were passionate about the service and wanted to ensure people had good quality support and improved outcomes. The provider’s 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 via regular individual conversations with people, tenants’ meetings, observations, surveys and care reviews. In the light of these, we make necessary changes.’ People and relatives confirmed that this happened.

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, “We have a good team culture, it is 1 big family, we all get along it is a nice team and nice environment”; “There’s 100% a positive culture, there is not a blame culture here” and “They do encourage an open culture, clients come first.”

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. 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 visited the services on occasion and was supportive and approachable. Staff 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, including easy to read accessible versions. The service had received 4 complaints in 2025. Records showed that these had been investigated and responded to appropriately. People knew how to complain if they needed to. People said, “I would tell staff If I was unhappy, they would help me” and “I would tell staff, the manager, [name] and mum and dad if I had a problem. They would listen and help me.” Relatives told us, “I have no concerns or complaints” and “I did have a complaint once a few years back, it was resolved and I was happy with how it worked out.”

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. The provider had an internal counselling service and some mental health champions to support staff (we reported in Caring that staff were not always aware of this support). Staff had annual appraisals as well as pay recognition based on performance. The registered manager 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, missing information in care plans, risk assessments, medicines, hazards to environments. Where audits had identified actions, these had been recorded and the management team had signed off items that had been addressed.

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 assured that incidents had been appropriately reported. People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. Staff said the management team were supportive and approachable. The provider had displayed their last inspection rating on their website.

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, “Those I am involved with are included, and encouraged to be involved in their support/decisions about their care, witnessed within meetings.”

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 such as improvements to risk assessments. Areas discussed during the assessment 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.