Netherclay 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.

This is the first assessment for this newly registered service. This key question has been rated 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 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.

Leaders created a positive and improving culture where staff felt supported and people’s needs were central to decision-making. Relatives consistently described the home as friendly, welcoming and well organised, noting, “The home seems to run fine… everyone is active” and that communication was open and transparent. Staff described morale as, “Much better,” and feedback showed a shared understanding of new ways of working, such as revised handovers and the breakfast club. The team demonstrated values of kindness, respect and attentiveness, contributing to a consistent, person‑centred culture.

The service 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 had the skills and experience needed to lead effectively. Staff and relatives spoke highly of the registered manager, with comments such as, “[registered manager] is brilliant… she is amazing, lovely and easily approachable.” The management team were visible and involved in day‑to‑day practice, with management attending handovers and working alternate weekends to maintain oversight. Staff told us leaders listened to concerns, acted promptly and created an environment where people felt safe and valued. Leaders promoted collaboration, continuous improvement and dignity in care.

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

Staff felt confident to raise concerns and understood the whistleblowing process. They told us they were listened to and trusted leaders to take appropriate action. One staff member said they felt, “Supported and confident that concerns would be acted upon.” Relatives also reported that when they voiced concerns or queries, leaders were responsive: “I would find one of the ones in charge… they are always responsive and listen.” This demonstrated a culture, where speaking up was encouraged and regarded as an essential part of improving care.

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.

The service promoted an inclusive environment where staff from diverse backgrounds worked respectfully together. Relatives acknowledged the team’s diversity and reported staff were, “All lovely people… very helpful, very understanding.” Training compliance included mandatory equality and diversity modules, and managers had ensured all staff completed the full induction programme and ongoing development. Staff described feeling respected and valued, and there was no evidence of discriminatory practice.

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.

Governance systems had strengthened under the new provider. Leaders had implemented improved auditing systems, including call bell audits, IPC checks, medicines audits and oversight of risk assessments. A mock inspection had been completed and the management team were actively working through an action plan. Environmental and safety checks were overseen well, with clear daily monitoring. Relatives confirmed they were informed of changes and invited to meetings. Leaders demonstrated good understanding of regulatory responsibilities, sustainable staffing, and the need for consistent documentation across electronic and paper systems.

The registered manager had been working closely with the local authority quality team to ensure processes were robust and effective.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service worked effectively with external professionals, including GPs, district nurses and therapists. Health and social care professionals reported prompt communication and confidence in the management’s responsiveness. Relatives described improved communication with professionals, and staff attended induction and training through the provider’s sister service, supporting consistency of approach. Residents remained involved in community life through visiting entertainers, family involvement, and regular newsletters.

The service 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 contribute to safe, effective practice and research.

The service demonstrated a clear commitment to learning and continuous improvement. Leaders responded constructively to the findings of the mock inspection, strengthened audits, and supported staff to complete a full re‑induction programme. The introduction of the new electronic care planning system was underway, with staff describing it as, “Making things a lot better.” The management team monitored themes from incidents, falls and clinical observations, using this information to update practice. Staff described the home as, “On the right path,” and evidence showed improvements in communication, documentation and care quality.

The service was preparing for future improvements, including implementing the new electronic care system and strengthening weekend management presence to maintain oversight across the week. Staff and relatives spoke positively about these changes, saying they were “On the right path” and progressing well under the new provider.

The provider has agreed to support CQC in piloting AI-assisted report writing demonstrating openness to innovation.