Delrose

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 requires improvement. At this assessment, 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.

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.

Improvements had been made following our previous inspection. The service 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.

Processes were in place to promote equality and diversity for people and the staff team. We reviewed the provider’s statement of purpose which clearly set out their values.

The manager told us, “Our values are caring, honest, 1 team, innovative, courageous, and equal. They are embedded in supervisions, appraisals, training, induction, they are on our screen savers, so all staff live and breathe them.”

Improvements had been made following our previous inspection. 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.

A professional told us, “I have visited the service on a number of occasions and noted a much-improved atmosphere from when I was first allocated. The physical environment has been decorated and made much more homely. People are encouraged to use the space instead of staying in their rooms. In particular Delrose have worked hard to rebuild very broken relationships with families, taking on board their concerns for the people and taking actions to address the concerns. The manager has worked hard to ensure that the people are dressed in good quality clothes so when they go out, they look smart, and she has discussed the importance of this with her staff.”

A staff member told us, “The manager has changed a lot at Delrose since they joined. They are working very hard to make this home better and to improve people’s lives. They are very supportive and take action when needed.”

We observed the manager to be supportive to both people and staff and was motivated to ensure the people living in the home were living their best lives.

Improvements had been made following our previous inspection. The service fostered a positive culture where people felt they could speak up, and their voice would be heard.

People living in the services were asked for their views and were given the opportunity to speak up on a daily basis both informally and in meetings. The manager told us action plans were devised from these conversations. This meant people’s views were listened to and drove improvement.

Improvements had been made following our previous inspection. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff felt supported to give feedback and were treated equally, free from bullying or harassment. They told us they had access to relevant policies.

The manager told us about the organisations flexible working policy which meant staff could apply for adjustments in their work to be made if needed. They gave examples of when this had happened in practice.

Improvements had been made following our previous inspection. The service 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 act on the best information about risk, performance, and outcomes, and share this securely with others when appropriate.

Staff understood their roles and responsibilities. Staff and the management team understood the importance of reporting any changes to people’s wellbeing. They kept detailed records of the support people had received. Governance processes were mostly effective in monitoring and improving the service. Where audits had failed to identify the shortfalls we found during inspection, for example with IPC, we were assured the provider took immediate action to rectify this.

There were security measures in place to ensure all paper and electronic information was stored safely and securely. The provider submitted information to partner agencies when required.

Improvements had been made following our previous inspection. The service 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.

Professionals, staff, and the manager shared with us positive examples of collaborative working in partnership. One professional told us, “The manager and area manager have always responded to any queries or concerns I have had as a social worker.It is my observation that people have been encouraged to engage back into the community, re-trying activities that had been stopped and going on holiday as would be an expected right for everyone. The manager in particular holds high aspiration for all of the people and is very proactive in identifying ways they can overcome barriers to ensure people have all their needs met.”

Improvements had been made following our previous inspection. The service focused on continuous learning and improvement across the organisation and local system. Staff and leaders were working to establish a consistent approach to improvement including monitoring progress and outcomes.

We reviewed evidence in team meetings, audits and quality assurance surveys which assured us learning was embedded, and the provider was continually striving to make improvements.

The provider had worked effectively to complete their action plan following their previous inspection. They had made the required improvements to meet the regulations and had maintained these improvements at the time of this inspection.

The provider was responsive during our inspection and the manager shared with us several ideas of how they wanted to improve people’s experience, these included introducing new activities both inside and outside of the home, which they had already begun to implement.