Spion Kop 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 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 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 and leaders were passionate about their work and showed a commitment to improving the lives of the people who lived at the provider.

The provider’s policies and procedures also reinforced the values of the organisation, with all staff being asked to read and sign to confirm that they had read these documents.

The values of the organisation were described in their statement of purpose, and we observed that the care and support reflected these values.

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 and other leaders spent a considerable amount of time in the building delivering care and interacting with people and staff, so there was a mutual respect between people, staff and leaders. This meant communication was open and leaders were approachable if anybody had concerns.

Supervisions and appraisals were completed on a regular basis, so staff had an opportunity to talk about their development and raise any concerns they may have in a confidential setting.

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

Posters which informed staff about how to speak up were on display around the building, and staff demonstrated a knowledge of speaking up and how to do so when we spoke with them. The provider had a whistleblowing policy in place which had a clear procedure which described the steps a staff member would need to take in order to raise a concern.

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 provider had a diverse group of staff who reported that they felt that they were included, respected and treated equally. Whilst the provider did not have a specific policy on equality, diversity and inclusion, the feedback we received directly from staff and through staff supervisions and surveys showed that the provider treated staff equally and inclusively.

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 provider had strong systems and processes in place to ensure good governance in all areas. The provider documented important information, and maintained a high level of recording on a daily basis which ensured analysis of any concerning trends could be completed.

Leaders completed regular audits that covered all aspects of the running of the home, from medication audits and accident and incident reports, to maintenance checks and IPC checks. When concerns were identified, the provider identified actions to address the issue. This showed the provider was looking to continuously improve and be proactive in spotting potential issues before they became major concerns. For example, when a medication error had occurred, leaders conducted a full investigation and put in rigorous new measures to prevent the issue occurring again.

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.

Care plans were informed by information gathered from people, their families, and partner organisations such as adult social care and healthcare professionals. This showed the provider took a joined-up approach to people’s care, valuing the contributions of everybody involved in people’s care.

Leaders understood the value of involving external professionals with expertise that could improve people’s lives. Referrals had been made to partner agencies such as mental health teams, SALT teams, nursing teams and advocacy organisations.

People attended a wide range of day centres and community groups, and leaders maintained good relationships with these organisations. This helped to ensure communication was good and people benefited from regularly partaking in activities in the community. For example, one person wanted to explore meeting people with similar interests and experiences to their own. Staff researched what groups were available in the local area and supported them to attend, attending with them until the person felt ready to attend the group without support.

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 had put robust systems in place for documenting people’s care and support. This meant there were accurate records which would allow leaders to analyse and reflect on learning. Incident reports and audits contained prompts which focused on learning from incidents, with action plans, designated staff and timescales identified. This meant learning and taking action was embedded in processes.

Leaders ensured staff received a wide range of mandatory training so all staff had a good grounding of knowledge. Supervisions and appraisals were used as opportunities for staff to identify any learning opportunities, with leaders supporting staff to receive extra training which was relevant to their role. In addition to mandatory training, staff were supported to gain care qualifications for their personal development.