Irchester 170

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

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 rated inspection, we rated this key question inadequate. At this inspection 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.

The provider was previously in breach of the legal regulation in relation to
governance. Improvements were found at this assessment, and the provider was no longer in breach of this regulation.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

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.

Since the last inspection, leaders had strengthened a shared sense of direction that was clearly understood by staff at all levels. They promoted a positive and inclusive culture where people’s rights, independence and wellbeing were central to the provider’s vision.

Staff told us they felt valued and supported, and that leaders were visible, approachable and actively involved in day‑to‑day practice. Comments from staff included, “It’s a much more cohesive place to work now, we are all on the same page” and “You can really see the shift in the staff team now, the manager has really moved the service forward and improved the culture of the home”

There was a strong emphasis on working collaboratively, with staff demonstrating a consistent understanding of the organisation’s values and expectations. This shared culture contributed to a cohesive team approach, ensuring people experienced care that was safe, respectful and aligned with the provider’s aims.

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.

Leaders were capable, compassionate and inclusive, creating a culture where people and staff felt respected and valued. They demonstrated a clear understanding of the service and the needs of the people who used it, and they modelled the behaviours and values they expected from staff. Leaders were visible and approachable, and staff told us they felt listened to and supported in their roles.

There was a strong emphasis on learning, reflection and continuous improvement, with leaders encouraging open discussion and welcoming feedback. This inclusive leadership approach helped to build trust, strengthen team cohesion and ensured people experienced care that was safe, person‑centred and aligned with the organisation’s values.

Relatives also shared positive feedback, telling us they felt informed, involved and reassured by the leadership team’s open and responsive approach. Comments included, “Everything is much better and improved. The registered manager is very good and gets things sorted” and “The change in leadership is much improved, we are regularly informed and communication has improved.”

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

Leaders promoted a culture where staff felt safe and confident to speak up. The provider had clear policies and processes in place to support Freedom to Speak Up, and staff told us they understood how to raise concerns and felt encouraged to do so. Leaders responded to issues in an open and constructive manner, demonstrating a commitment to learning and continuous improvement. Staff described an environment where transparency was valued, their voices were listened to, and concerns were acted upon.

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.

Leaders promoted workforce equity and diversity, creating an environment where staff felt respected, included and able to thrive. Recruitment and development processes were fair and transparent, ensuring opportunities were accessible to people from a wide range of backgrounds.

Staff told us they felt valued and that the organisation celebrated diversity, with leaders actively encouraging open discussion about equality and inclusion. Training supported staff to understand and challenge discrimination. This approach contributed to a positive culture where staff felt empowered and people benefited from a team that reflected and understood the diverse communities they served.

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.

Since the last inspection, the registered manager had strengthened governance oversight, ensuring clearer accountability and more consistent monitoring of quality and safety. Leaders had effective systems in place to review performance, identify areas for improvement and track progress against agreed actions.

Area management had implemented peer management audits across local services to strengthen systems and develop shared practice, creating greater consistency and opportunities for learning. Audits were thorough and regularly completed, with learning shared across the team to support continuous improvement. Staff understood their roles within the governance framework and felt supported to contribute to ongoing development.

However, governance systems to effectively manage and maintain a safe environment and IPC practices were not established at all levels to ensure consistent oversight and robust risk management, meaning the environment was not always maintained to the expected standard of safety and cleanliness, including IPC practice and oversight, increasing the risk of avoidable harm and infection transmission.

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 fostered strong and effective partnership working with external professionals and organisations to improve outcomes for people. Partners told us communication was open, timely and constructive, and leaders were proactive in engaging with them to support coordinated care.

Commissioning teams shared positive feedback about the service and reported improved outcomes for people as a result of this collaborative approach. Staff benefited from these strong relationships, which helped them respond to people’s changing needs in a consistent and joined‑up way.

The management and senior team regularly attended multi‑agency meetings and sought specialist input when required, demonstrating a commitment to integrated working. This approach strengthened continuity of care and ensured people experienced a service that was well connected and responsive.

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.

Leaders promoted a strong culture of learning, improvement and innovation, ensuring the service continued to develop in response to people’s needs. They encouraged staff to reflect on practice, share learning and contribute ideas for improvement, creating an environment where continuous development was embedded in everyday work.

Systems for reviewing incidents, feedback and performance data were well established, enabling leaders to identify themes and implement changes that improved outcomes for people. This commitment to learning and improvement helped ensure the provider remained responsive, forward‑thinking and focused on delivering high‑quality care.