Glebe Villa

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.

The service was previously in breach of regulations relating to governance. Improvements had been made, and the service was no longer in breach of regulations.

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 registered manager told us, “As a care home, we aim to promote independence, dignity, respect and support people to reach their own potential and to support people to lead ordinary lives within a caring and inclusive family environment. Comments from visitors, professionals and relatives confirmed there was a welcoming and homely atmosphere when they visited.

There was a strong commitment echoed by all staff to provide care that was tailored to the person enabling them to do the things they wanted to do both within the home and the community.

It is a legal requirement that a provider's latest CQC inspection report rating is displayed at the service where a rating has been given. This is so that people, visitors and those seeking information about the service can be informed of our judgments. We found the provider had displayed their rating at the service and on their website.

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 told us since the last assessment they had completed some online courses to support managers in care homes with skills for care. They had increased their knowledge on the legislation and the requirements of the Care Quality Commission. The provider and an area manager supported the registered manager. The senior management demonstrated they knew people well and had a strong presence in the home. People spoke positively about the management of the service and knew who everyone was. One person said, “(name of area manager) and (provider) visit us lots.”

A deputy manager supported the registered manager. The registered manager recognised the skills of the staff team including their strengths for example linking people with similar interests or helping with paperwork and household chores. It was evident the team were cohesive and worked together to support the people living in Glebe Villa and each other.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. Staff felt the culture enabled them to speak up. Staff felt confident their voice would be heard, and the management team would address concerns.

There were policies and procedures for staff to follow should they wish to speak with external agencies. This included the local authority, CQC or the police in respect of concerns and allegations of abuse.

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.

There was a diverse workforce, and this was valued. Staff and the management team were positive about working for the provider, and the people they supported. Staff had access to regular supervision and were encouraged to raise any concerns with their manager or the senior leadership team.

Staff were provided support through relevant training to inform their knowledge and understanding of equality, inclusivity, and fairness in the workplace. Staff told us they supported with reasonable adjustments including adjusted working hours, and flexible rota arrangements. Policies and procedures were in place to guide staff.

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.

Since the last assessment governance arrangements had improved and the provider was no longer in breach of regulations. They had addressed all the issues we had identified at their last assessment, and no new concerns were found at this assessment.

Systems were in place to monitor the care provision, health and safety, medicine management and record keeping. Where audits had identified shortfalls an action plan was in place to drive improvements. This was monitored by the provider and the area manager to ensure ongoing compliance.

The provider has a legal duty to report certain events that affected the wellbeing of a person or affected the whole service. Relatives confirmed they were kept up to date with any changes, incidents or accidents. From reviewing the accident and incident log the service was reporting appropriately to the Commission. There had been very few incidents that were reportable to us.

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 registered manager worked closely with various health and social care professionals to help enhance people’s life and wellbeing. This ensured continuity of care and improved systems and processes.

People were supported to maintain contact with people that were important to them. Relatives confirmed they could visit their loved ones and were involved in their care.

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.

The provider had taken action to improve the service since our last assessment. They had addressed the areas of concern found and improved the safety and quality of the service. For example, changes made included ensuring staff were recruited safely and completed relevant training enabling them to support the people living at Glebe Villa. Governance arrangements had driven improvement which continued with an improvement plan in place to drive further improvements to the quality of life for people.

People had been involved in developing the improvement plan, which incorporated their wishes for example various trips to place of interest, holidays and events that were held in the Bristol area such as the Balloon Festival.

The registered manager told us they attended 6 monthly meetings with other managers working with the provider to share learning.