Clifden House Dementia 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 since the provider changed their registration. This key question has been rated good. 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 had specific training on equality and diversity and had a good understanding of how to enable people to have a good quality of life. Staff told us they enjoyed working at Clifden House Dementia Care Centreand felt involved and included. There were regular team meetings, daily handovers and manager meetings.

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 registered manager attended care forums to share knowledge and ensure they were up to date with national practices and guidance. Staff spoke highly of the management team, how they were supported and offered them guidance whenever they needed. Relatives told us how the management team were always available and approachable.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. There was a whistle blowing policy in place and staff knew how to raise concerns. The registered manager told us there was open door policy and there was a suggestion box staff could use anonymously if they wished. Staff told us they felt the management team were approachable and they could talk to them anytime and they always supported them.

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. All staff had equality and diversity training. Staff feedback was positive about the support they received, they felt respected and supported. Staff told us, " The registered manager and team leaders, we have a good relationship with them, they help us if we need any help or any concerns, we directly approach them."

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. The management team had effective quality assurance oversight and carried out regular audits and checks to monitor and improve all aspects of care they delivered. The registered manager told us how they carry out monthly audits and they carry out staff audits around training and recruitment. The registered manager carried out dependency assessment checks based on staffing levels and people's needs to ensure there was enough staff on each shift to meet people needs.

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 registered manager told us how they worked in collaboration with outside agencies and ensured people got the support they needed to attend appointments and staff supported people to attend appointments. The registered manager told us about they had a range of community services coming in that people were observed enjoying during our visit, such as a singer. People went out to the dementia café, or the pub and the church held a service at Clifden House Dementia Care Centre.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. There were good clear processes in place that demonstrated how learning was taken forward. The registered manager had good oversight of accidents and incidents and did an analysis weekly to look for patterns, trends and learning opportunities. We viewed some incidents and accidents, and these were followed up in care plans. We spoke with staff about reporting incidents and accidents and staff were knowledgeable about the correct procedures to follow.