Abbey Grange Nursing 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 assessment we rated this key question good. At this assessment the rating has remained/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.

This service scored 68 (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 management team demonstrated a culture of openness and transparency. People, relatives and staff told us there was an open-door policy, and staff were encouraged to ask for guidance or report any concerns. The registered manager embraced the provider values and incorporated them in everyday practice.

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 were committed to providing the best care and support for people. Where incidents occurred, the provider and management team were transparent and open and shared details of the events with relevant parties.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had a whistle blowing policy and staff felt comfortable to raise concerns about the service. Staff were confident the provider and registered manager would take their concerns seriously and respond in a positive way. One staff member said, “I am confident that the home manager would take appropriate action.”

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. Processes were in place which helped to protect the rights of staff under the Equality Act. This helped to create a more equitable and inclusive organisation. There was also evidence of reasonable adjustments, for staff who required them. Staff told us they enjoyed working at the service and felt staff morale was high. One staff member said, “Staff morale is generally happy and positive. This isn't a job you can do if you don't enjoy it.I wouldn't have an issue with family and friends to be cared for at Abbey Grange.”

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems were in place to monitor the service but had not always been effective in identifying areas for improvement. There were auditing processes of care documentation in place which both senior care staff and leaders of the service completed. However, these audits had not always identified mistakes in documentation such as level of food diet, which placed people at risk of harm. The infection control audit had not always identified the issues we found with the cleanliness of the service. The provider has advised us how they plan to improve systems and processes to ensure robust governance, having already implemented some positive changes.

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 interacted well with external professionals to ensure timely referrals took place as required.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. During our inspection we found areas where the provider had learnt from incidents and others where not enough appropriate action had been taken. The management team demonstrated a commitment to improving people’s experiences, outcomes and quality of life by encouraging new ways of working and promoting reflective practice. These initiatives were still in their infancy and required time to fully embed and demonstrate sustained improvements in the service.