Safe Harbour Dementia Care Home

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 inspection we rated this key question good. At this assessment the rating has remained 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 75 (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 managers were approachable, supportive and responsive, and described the home as a good place to work. Several staff stated they would be happy for their own relatives to receive care at the service, demonstrating confidence in the quality of care provided. A professional also spoke positively about the service and told us communication was good and concerns had always been appropriately addressed.
Staff understood their roles and responsibilities and there was evidence of a shared commitment to providing high-quality care for people living with dementia. Daily huddles, team meetings and regular staff debriefs, helped ensure important information was communicated consistently and that staff remained focused on achieving positive outcomes for people. Leaders had created a culture where teamwork, respect and continuous improvement were promoted across the service.
 

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. Managers had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.
The management team demonstrated a good understanding of the needs of people living at the service and maintained oversight of quality and safety through regular reviews, audits and meetings. Staff told us they felt supported in their roles and had access to training, supervision and development opportunities.
We also saw evidence of the management team responding promptly to concerns identified during the inspection, including environmental issues which were addressed immediately and incorporated into improvement plans. Feedback from a healthcare professional was positive about leadership and management of the service, with the professional describing managers as very good and praising the service's communication and support provided to people and relatives.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Staff demonstrated a good understanding of safeguarding responsibilities, whistleblowing processes and escalation procedures. Staff told us they would feel comfortable raising concerns and were confident managers would listen and take appropriate action. Discussions with staff showed they understood how concerns could be escalated externally if required, including through safeguarding processes, the police and CQC. The provider had policies and procedures in place to support whistleblowing and freedom to speak up, and these outlined clear reporting pathways and protections for staff who raised concerns. We also saw evidence that resident meetings, family engagement opportunities, complaints systems and feedback processes were used to gather people's views and experiences. Relatives spoken with told us they felt able to approach staff and management should concerns arise. These systems helped to promote an open culture where feedback was welcomed and used to support improvement.
 

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.
We spoke with staff from a range of backgrounds who told us they enjoyed working at the service and felt valued by colleagues and managers. Training records showed staff completed equality and diversity training alongside other mandatory and specialist learning. The registered manager had developed champion roles in key areas, including dignity and mental capacity, enabling staff to share knowledge and support good practice. Leaders also demonstrated a commitment to understanding and celebrating people's diverse experiences.
 

The provider had clear responsibilities, roles, systems of accountability and good governance. 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.
We found a comprehensive governance framework supported by a wide range of audits covering care planning, medicines management, infection prevention and control, catering, housekeeping, health and safety and environmental standards. Responsibility for audits was distributed across departments, helping to promote accountability while maintaining senior management oversight. Audit findings were reviewed and actions monitored through monthly plans and ongoing quality assurance systems. The management team reviewed accidents and incidents through daily huddles and monthly analysis, and we saw evidence of learning being implemented when trends were identified. Systems were in place to ensure required notifications were submitted appropriately and policies provided clear guidance for staff. Whilst some care records contained duplication and occasional inconsistencies between summaries and review records, risks were generally identified and managed appropriately. The provider recognised the need to continue refining documentation to make important information easier for staff to access. Overall, governance systems supported safe, effective and sustainable care delivery.
 

Staff 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.

Records demonstrated strong partnership working with a range of external health and social care professionals, including GPs, district nurses, speech and language therapists, falls teams, physiotherapists, mental health services and community healthcare teams. Staff used professional guidance to support people's health, wellbeing and safety. The provider demonstrated a commitment to working beyond the boundaries of the service. They had established a Care Academy to support training and skill development within the wider care sector and the registered manager actively participated in care home manager networks and professional learning groups.
 

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 management team drove continuous learning through daily huddles, weekly debriefs, team meetings, incident reviews and audits. They used information from these activities to monitor performance, identify trends and improve care. The registered manager analysed accidents and incidents, sought healthcare input when patterns emerged and acted on lessons learned. They promoted innovation through initiatives such as the Care Academy, offering training opportunities across the wider sector. The management team welcomed external scrutiny, achieved recognition, and developed projects to support families and carers in the community. Staff carried out reflective reviews following end-of-life care to identify learning and improve future practice. These actions demonstrated a strong commitment to learning, innovation and continuous improvement.