Gwen Walford House

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 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 79 (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. Rotherwood Healthcare had a clear vision and core values which was outlined in their Statement of Purpose. The registered manager told us 2 key values of the service were compassion and kindness, and they liked to lead by example by having an open-door policy. The registered manager told us, “Staff know they can come to me; they can also go to (Regional manager), there is an open-door policy, very honest, very straight to the point, I make sure there is no secrets. We have a culture and mentoring attitude, instead of punitive approach”. Staff spoke positively about the support they received from the management team. One staff member told us, “They support me, they really support us, and they inform us of whatever we need to know. (Registered manager) takes action, she listens to what we have to say”.

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. There had been some recent changes in the senior management team, and they were in the process of implementing and embedding some new audit and leadership processes. The registered manager and senior management team were open and honest during the assessment and shared some of the challenges they have overcome and where they had seen improvements. The registered manager told us “I feel supported, my line manager is absolutely fantastic. We have a structure of the new compliance and quality. We have incorporated some new compliance processes, but this is on-going”. There were systems and processes in place to support staff to develop their roles and there were opportunities for staff to develop their knowledge and skills if they chose to. For example, some staff had taken on roles as sleep champions, which was a new role to capture information about people's routines at night.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People had the opportunity to share their views of the service through residents meetings. Feedback from people and relatives showed they felt comfortable to share any concerns with staff or leaders. Staff had opportunities to make suggestions and contribute to the development of the service at staff meetings, surveys and through the provider's supervision procedure. The registered manager understood their responsibilities under the duty of candour. The duty of candour is to be open and transparent, and it sets out specific guideline's providers must follow if things go wrong with care and treatment.

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. The service promoted an inclusive and fair culture, and staff we spoke with told us they were treated fairly, staff spoke of how they supported each other when help was needed on different floors of the service. One staff member told us, “We are all very good, we are working as a team and we enjoying working together. You need to help each other as some people require double handed care”. The service had an equality and diversity policy in place to guide equitable and fair recruitment and selection procedures. Staff had received training in equality and diversity.

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 service's senior leadership team were in the process of embedding some new governance and compliance documentation. For example, it had been identified there were too many audits, which were unnecessary. The leadership team had revisited the effectiveness of their audit processes and found they were able to reduce the number by focusing on themes and trends to drive improvements. Some of these processes still required further embedding as it had not always highlighted some of the issues we found during the assessment. The registered manager had the opportunity to have interactive sessions with senior leaders and the Nominated Individual to discuss their top 5 risks at the service. Meetings with staff at different levels took place to discuss the service and reinforce areas of good practice, lessons learnt and areas for improvement. Actions were set with staff allocated to complete and review them. There was a contingency plan in place which provided guidance in case an issue occurred which impacted the provision of care.

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. We received limited feedback from external professionals, however there was evidence in care plans and when talking with people to demonstrate the registered manager and staff worked in positive partnerships with external health professionals. People were encouraged to maintain relationships with those who were important to them and engage in activities which were meaningful and improved their quality of life. The provider had a number of external agencies which regularly visited the service to offer entertainment and interactive sessions.

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 were passionate with promoting learning and improving the service and told us this was important to them. There was an understanding of learning from when things had gone wrong and sharing feedback with people and staff to ensure lessons were learnt. The registered manager and staff shared some new projects they are currently working on. The registered manager told us, “We have a sleep gap report - as a company we try being more personalised. You have your hourly checks and residents that may not need them. We now have sleep champions capturing information about people's routines at night. We are looking to become more personalised to make sure people have their bedrooms as they want them. This considers the temperature, lighting, and whether the curtains are drawn or open”. The registered manager told us they are completing personalised sleep reports, and this will be filtered into people’s care plans. The service was also working on a hearing loss project, which was aimed to enhance the quality of life for people with hearing loss, to reduce social isolation and the risk of falls.