Capwell Grange 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 inspection we rated this key question requires improvement. At this inspection, 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 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 registered manager and management team 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 understood their main role was to support people to have the best experiences possible. They had taken their time to get to know people well and treated them with respect. They told us and their practice showed they treated people the way they would treat their own relatives and friends. The registered manager and management team had worked hard to create a positive culture at the service. People were happy and relaxed being supported by staff. Feedback from people, relatives and professionals about the service was mostly positive and the service was described as having a friendly atmosphere. One person said, ‘‘[Staff] are marvellous and are so kind to you. If you need anything they sort it out straight away’’ A relative told us, ‘‘The staff are really good. [Family member] came into the service really unwell and has improved both in their physical health and in their wellbeing. They are much more content and happier now.’’

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support. They did so with integrity, openness, and honesty. The registered manager and management team were an active presence at the service, spending time with people and staff. They listened and took feedback seriously. As a result, people and the staff team felt included in discussions about the running of the service. Staff felt well supported by the management team. People and relatives told us the management team were kind and caring. Most people and relatives knew the manager of each of the 5 ‘units’ at the service and had them as a point of contact rather than the registered manager who kept more of an overview of the whole service. One person said, ‘‘I speak with [manager] every day and [registered manager] comes down every now and then to see how I am.’’ A relative told us, ‘‘The service is well run, and I like how it has been set up into smaller ‘units’ to give it more of a family feel.’’

The provider fostered a culture where people felt they could speak up and their voice would be heard. However, we received mixed feedback from relatives about communication to and from the service. Some relatives told us they did not hear from staff at the service unless there was an incident or a problem in relation to their family member. They also told us they were not always aware of opportunities to attend meetings to speak up. The management team told us they would address this with people’s relatives to help improve opportunities for them to speak up with confidence. There were policies in place and staff knew how to speak up and raise concerns and told us they would feel comfortable doing this. People and relatives knew what to do if they needed to make a complaint and were assured that these would be investigated and taken seriously. The management team kept a record of concerns and made sure people were responded to with a resolution and any changes that would be made as a result of the concern being raised. One relative said, ‘‘If you do have a problem, it is resolved very quickly.’’

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. Staff felt well supported and told us they could approach the management team to have discussions about any help they needed in their job roles. The provider supported their equality and wellbeing by offering preferred working patterns and discussing their job roles with them regularly. The provider’s recruitment process was fair and equitable.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. Despite audits being in place, they had still not picked up on some of our findings at this inspection. This included improvements being needed in relation to IPC, supporting people consistently with their communication needs, ensuring people did not go long periods of time without meaningful engagement and ensuring relatives and family members felt well communicated with. The way in which lessons could be shared across the 5 ‘units’ of the service could also have been strengthened. However, during the inspection we were assured by the management team and shown evidence these audits would be strengthened.

Most audits and governance measures had proven to be effective in identifying and addressing issues. The provider also completed checks and audits to monitor the quality of the service. Plans were in place to help ensure the sustainability of the service.

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. People saw health professionals if this was needed. Visiting professionals were positive about the staff team and how they worked with them. The management team worked well with partners such as the local authority. Staff supported people to places of interest in the local community on occasions. People were supported to be a part of their local community at the service and take part in events such as garden parties and religious celebrations if they chose to do so. One person said, ‘‘I am enjoying [social pastime]. I am happy here.’’ A professional told us, ‘‘I would say we have a strong working relationship with [management and staff team] which benefit people.’’

The provider and registered manager 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. The management team had improvement plans in place based on findings from internal and external audits. Actions on improvement plans were monitored to help make sure improvements were benefiting people using the service. Staff told us they were involved in discussions and meetings about the service and their feedback about how to improve the service was listened to and taken seriously. There were some minor areas for improvement identified at this inspection in areas such as IPC, a lack of meaningful engagement for some people at some times of the day and how people were supported to understand information. Immediate action was taken by the management team to start rectifying these and we were assured improvements would be made. A relative told us, ‘‘[Family member] is getting better and better every day since living at the service. We are very satisfied with their care and support.’’