Archived: Clifton 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.

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.

At the last inspection the service was in breach of regulations regarding the effective management of the service. Enough improvements had been made, and the provider was no longer in breach of regulation.

This service scored 71 (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. People, their relatives, and staff all felt listened to by the service. Everyone felt their views were valued and respected. People were encouraged to provide feedback on the care they received. Any outcomes or changes because of feedback was shared with people. One person told us “I know who the manager is, and they are approachable.” We saw members of the management team chatting with people and relatives in a relaxed and open way promoting relationships and supporting open communication.

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 kept themselves up to date with learning and attended regular upskilling sessions to ensure they had the skills to effectively manage the home.

The provider had taken the opportunity to commission external consultants to support them. The were open to recommendations and acted on advice and guidance. For example, following a review of a care plan they acted on all the recommendations and then rolled this out to everyone’s care plan to ensure lessons learnt were consistently applied.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. People, relatives and staff felt able to openly speak up about anything that concerned them. Staff members had access to policies which informed their practice including the whistleblowing policy. All those we spoke with felt they would be supported if they needed to raise a concern. One staff member said, “I know I can go to the manager or provider or the CQC or Local Authority. All the contact details are in the reception area if I need them”

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. All staff members we spoke with stated they felt they were treated equally and supported fairly. Staff were aware of policies and procedures including, but not limited to, antidiscrimination procedures, which informed their working experience.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Although the provider did have some quality assessment tools in place they failed to identify the issues we found at this inspection or to act proactively in addressing them. For example, they failed to ensure appropriate signage was in place, the improvements which were needed to the cleaning schedules or the lack of a legionella risk assessment, albeit they were doing bacteria tests and flush throughs.

However, in other areas of the care provision if the management team identified ‘Shortfalls’ in care they addressed this promptly and consistently. For example, the provider had introduced “Lets talk” sessions where improvements could be identified in a supportive way with individual staff members.

The service 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 were supported by staff and the management team to engage with their local communities and partners. This included GP’s, and others involved in their care and support. This supported people to remain in control of their own care and supported their own independence.

The service focused on continuous learning, innovation and improvement across their organisation. They encouraged ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice. Staff had access to team meetings and records confirmed the provider acted when they received feedback. Any lessons learnt or positive approaches to care were shared with the providers partner location to share improvements and developments across both services.