Grosvenor 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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

The provider was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.This meant the provider 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.

At the last assessment, the service lacked a clear vision and consistent culture, leading to uncertainty among staff. Since then, leaders have clarified the service’s values and goals. Staff now understood the service’s purpose better and showed a positive, person-centred attitude.

Staff knew the provider’s ethos and demonstrated it in their work. They communicated openly with each other, regularly discussed the best way to support people, and adapted their approach based on people’s needs. There was a shared sense of responsibility for maintaining high standards and supporting improvement.

Leaders encouraged open discussion about potential risks, including the early signs of a closed culture. They promoted reflection through team meetings, daily handovers, and audits. The culture was one where staff felt safe to raise concerns, and where people’s rights and choices were at the centre of decision-making. Staff made efforts to adapt around individuals, rather than expecting people to fit into set routines. For example, one person preferred going to a specific barbershop where they felt comfortable and more confident to speak. Staff recognised how important this routine was to the person’s well-being. Another person enjoyed visiting a place of worship for the food and atmosphere, even though they didn’t follow the religious practices. Staff respected this and supported their attendance.

Staff understood the importance of enabling people to live the lives they chose and worked closely with families and professionals to avoid institutional practices.

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.

At the last assessment, there had been a failure to ensure proper staff training and oversight, especially around medicines management. Now, leaders carried out regular staff competency checks and provided ongoing support. Staff reported better morale and felt leaders were more responsive and compassionate.

The leadership was values-driven, inclusive and person-centred. They modelled openness, compassion and integrity in both words and actions. Staff described the registered manager as “hands on” and “always accepting,” another said, “he’s the only one some people respond to.” This reflected the trust and connection leaders had built with people and the team.

The registered manager framed their role as being part of the people’s lives, and stated “this is their home”, and ensured people had choice and control in their routines, activities, and care planning. Improvements were underpinned by strong governance. The visible leadership presence, daily planning meetings and walk arounds ensured issues were identified early and resolved quickly. Regular feedback from relatives, GPs, social workers and visiting professionals were actively sought and used to improve outcomes. The team had strong systems in place to regularly check and improve the quality of care. Electronic care plans with prompts alerted staff to required reviews.

Leaders promoted inclusion, equality and human rights through meaningful action. People’s diverse needs, religious, cultural, dietary, and linguistic, were respected and reflected in daily life. Activities, outings, and food were adapted accordingly. Visual, easy-read and translated feedback forms ensured people with communication needs could also share their views. One person, for example, continued to visit their temple each week because as the registered manager said, “[The person] loves the food’. Staff ensure it’s prepared safely and in line with relevant guidance. Leaders had the skills, knowledge and credibility to guide safe, personalised care. They were honest about things that went wrong before and worked hard to keep making things better. Their leadership approach enabled people to live fuller, more autonomous lives.

The provider fostered a culture of openness, trust, and psychological safety where staff felt confident raising concerns. There were clear and safe systems in place for people to speak up, and leaders actively encouraged open communication.

At the last assessment, we had identified weak systems for reporting concerns, and incident reviews lacked follow-up, which discouraged openness. At this assessment we identified improvements. This meant staff and residents could now raise concerns safely. Investigations now included actions to prevent repeats, and staff felt more comfortable speaking up.

A designated care worker had now been given a colleague ambassador role to provide a confidential point of contact for staff who may feel uncomfortable raising concerns directly with management. While most staff chose to speak to the registered manager directly, this role created additional reassurance and promoted a transparent and supportive workplace.

Leaders were approachable and visible. The registered manager told us “99% of the time [staff] just come in and speak to me” and was described by staff as highly responsive and “always accepting”. This was supported by a strong culture of feedback and daily interaction, including spot checks, team meetings, and engagement with external professionals. District nurses, and local pharmacies were all encouraged to provide feedback to support learning and improvement.

People using the service were supported to express their views. The staff used accessible feedback tools such as visual forms with symbols and large print, helping individuals to participate meaningfully in discussions about their care. There was a complaints and compliments box in the dining area and also an employee of the month voting box.

The provider focused on supporting people to thrive, learn new skills, and lead enriched lives. Staff worked closely with families, speech and language therapists, and other professionals to ensure each person could participate in ways that were safe, empowering, and respectful of their identity.

Together, these actions reflected a culture where staff and people using the provider were listened to, involved, and empowered.

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.

At the last assessment, training on equality and inclusion was inconsistent, and support for diverse needs was limited. Now, staff received regular training and made reasonable adjustments for people’s cultural and communication preferences. The service promoted respect and inclusion for all.

Management actively promoted equity among staff and celebrated the diverse backgrounds, experiences, and strengths within the team. Staff came from a wide range of cultural and ethnic backgrounds, and the provider recognised that this diversity enriched the service provided.

Training was inclusive and accessible. The registered manager adapted communication methods, such as simplifying language or providing extra support, for staff whose first language was not English. This ensured all staff understood policies, procedures, and training expectations, contributing to a safer and more unified environment.

The management focussed on creating an inclusive and welcoming workplace. Cultural holidays and national celebrations were regularly marked with themed meals, decorations, and discussions with people being supported. For example, the team celebrated independence days for countries represented in the staff group, with traditional food and music. These events brought staff and residents together and promoted mutual respect and cultural awareness.

Staff morale was supported by celebrating every colleague’s birthday, and team-building activities such as outings, team dinners, and shared events like bowling or golfing were arranged at least quarterly. These activities helped foster a sense of belonging and appreciation among the team.

The registered manager ensured that staff felt heard and supported through regular supervisions, open-door access, and through the colleague ambassador role, which allowed concerns to be raised confidentially.

Overall, staff consistently reported feeling respected, supported, and valued, which contributed to a positive culture of inclusion, collaboration, and psychological safety.

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.

At the last assessment, governance systems were ineffective, with poor risk monitoring and no clear improvement plans. This had changed. Regular audits and action tracking were now in place. Incident and complaint handling had improved, with a stronger focus on preventing problems and sustaining quality care.

At our last assessment, the provider was issued a warning notice for a breach of the regulation for good governance. Quality assurance systems were not effective in identifying or addressing risk. Audits failed to detect errors in medicine management, risk assessments were not consistently updated after incidents, and learning from accidents or near misses was limited. There was no clear audit trail to demonstrate actions taken or improvements made in response to concerns.

At this assessment, we found these issues had been addressed. Governance systems had improved, with regular audits now in place covering key areas such as medicines, incidents, and care plan updates. Risks were monitored and reviewed consistently. The provider had systems to identify concerns early and to implement learning from incidents. These improvements meant the previous breach had been met.

Daily meetings helped plan each day and make sure everyone knew what was needed. Important updates were shared between staff teams, and regular checks, like medication audits and care reviews, helped catch issues early. If something needed to change, it was added to an action plan and fixed, often within a few weeks.

The provider used up-to-date digital care planning tools, which gave automatic reminders to review care and risk assessments. This helped ensure that people were kept safe without unnecessary delays, and the support they received reflected their current needs.

Care and support were shaped around what each person needed and wanted. Staff worked with individuals, their families, and professionals to help them live life their own way, enjoy activities, and make choices that mattered to them.

Altogether, strong leadership, regular reviews, and good communication helped keep the provider safe, caring, and centred around the people who live there, now and for the future.

The provider built a culture focused on enabling people to live meaningful lives, shaped by their choices, strengths, and interests. Leaders worked closely with people, their families, and staff to understand what mattered most and used this insight to guide care planning, goal setting, and daily routines.

At the last assessment, partnership working with health and community services was inconsistent, affecting care coordination. Now, the service worked closely with GPs, dietitians, nurses, and advocates. They also engaged with local community resources to support people better.

Staff collaborated with health and social care professionals to provide coordinated, responsive care. Regular reviews and joint visits ensured changing needs were quickly addressed, and professional input was used to reduce risks and promote independence.

People were supported to stay connected to their communities through activities that reflected their cultural identities and personal interests. People were regularly involved in community activities tailored to their preferences, such as visits to places of worship, parks, markets, libraries, and outings to culturally relevant locations. Activities were not tokenistic; staff adapted them to maximise engagement and enjoyment, even when individuals had limited understanding of the context, focusing instead on the sensory or social aspects that were meaningful to them.

Staff encouraged people to try new experiences and develop confidence, and adapted support flexibly around each person’s preferred way of engaging.

This inclusive, person-led approach helped people build the skills, confidence, and relationships that supported a good quality of life.

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.

At the last assessment, there was no effective system to learn from incidents or complaints, and improvements were mostly reactive. The service now used investigations and feedback to plan and make ongoing improvements. Staff were encouraged to share ideas and improve how care was delivered.

The provider had switched from paper records to digital systems to work better and keep track more clearly. Staff used digital alerts to do tasks on time, make fewer mistakes, and quickly respond when people’s needs changed. This helped make sure care was safe, effective, and personal to each person.

Innovation was embedded in daily practice. For example, staff adapted physiotherapy routines based on what helped people to engage better, rather than relying on fixed schedules. Creative tools such as easy-read and pictorial feedback formats enabled people with communication needs to share their views and influence improvements.