Amy Woodgate

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 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 new managers described the values of the provider and explained how these were applied to ensure they employed suitable staff. Managers told us they routinely used individual and group meetings to remind staff about the provider’s underlying core values and principles. They supported a reflective practice approach, establishing a learning culture to support staff to deliver good quality person-centred care. Staff told us they felt supported by the managers to deliver consistently safe, person-centred care to people in line with the provider’s vision and values for the service.

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 provider had made improvements since our last inspection and now had a new management team in place who were suitably skilled, knowledgeable and experienced, which included a new registered manager, a deputy manager and a regional manager. This new management team understood the context in which the service delivered care and support and embodied the culture and values of their workforce and the provider. They were experienced and undertook continuous learning and development to maintain their skills and knowledge. They also had a good understanding of the needs of people living in the care home and how these should be met through the provision of safe, person-centred care. People’s relatives and staff were generally positive about the leadership approach of the relatively new management team which they consistently described as professional and supportive. One relative remarked, “I think the new managers have significantly improved the care home is a relatively short period of time and continue to move in the right direction. They’re all doing a grand job of running the place.” A staff member added, “I like the new managers. They’ve done a good job to improve the care home in the last year.”

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

The care home had an open and transparent culture where people living there, relatives, external health and social care professionals and staff were all encouraged to raise concerns without fear. The provider used a range of methods to gather people’s views about what the care home did well or might do better. People living in the care home and their relatives were routinely invited to attend group meetings with managers and staff. The provider valued and listened to the views of staff. Managers told us they explained the complaints process before people moved into the home. Staff were encouraged to contribute their ideas about what the service did well and what they could do better during regular individual and group meetings with their line managers and fellow co-workers.

The provider 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 were positive about the leadership approach of the new management team who they said treated them fairly and had significantly improved the service in a relatively short period of time. Staff told us their views were always respected and listened to by the managers and they felt valued as members of the team. Managers understood the importance of having a fair and inclusive workplace for all staff to work in. Staff were provided support through relevant training and supervision to inform their knowledge and understanding of equality, inclusivity and fairness in the workplace.

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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Governance systems were well-established, effectively operated and used to regularly check and audit the quality and safety of the care and support people received. The providers internal quality assurance team routinely conducted on site checks and audits of the care home. In addition, the managers and senior staff who were permanently based in the care home also routinely undertook checks to make sure staff were delivering the packages of care and support set out in peoples care plan. They demonstrated a good understanding of their governance roles and responsibilities in relation to assessing, monitoring and managing the quality and safety of the service they provided. The outcomes of all these checks and audits were used to identify performance shortfalls which fed into an action plan to improve the quality and safety of the service people received. Managers and senior staff representing the care, catering and domestics teams regularly met to discuss identified issues and agree action plans to resolve any identified issues.

Managers understood their responsibilities in relation to regulatory requirements around notifiable incidents. The provider continued to notify the CQC in a timely manner about any incidents and events they were legally required to.

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 service demonstrated effective partnership working. Managers and staff engaged proactively with relevant external health and social care professionals and organisations, with established systems for regular sharing information and learning. Guidance and recommendations from those partners were embedded into practice to support staff development and drive continuous improvement in the safety and quality of service.

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.

Systems were in place to review performance, identify learning opportunities and adapt practice. The provider routinely analysed the outcome of audits and checks they regularly conducted to identify performance shortfalls and learn lessons. When lessons needed to be learnt, the provider developed time specific action plans which set out clearly what, how and when they needed to take steps to improve the service they provided people. Staff confirmed information about any lessons that needed to be learnt and changes to policies and procedures were regularly shared and discussed with them at individual and group meeting. Staff took part in regular training and meetings with the management team.