Hodge Hill Grange

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• 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 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 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.

Staff and the management team demonstrated a positive, supportive and compassionate culture, both towards one another and the people living at the home. Equality and diversity were actively promoted, and staff were able to describe how they applied these principles in their daily practice.

The provider’s vision, values and philosophy were clearly embedded within the service. These emphasised kindness as a core principle, focusing on caring for people by understanding what matters most to them as individuals. Staff told us this was introduced during their induction and reinforced through ongoing training and regular team meetings. They described how these values shaped their approach to creating a warm, welcoming community and supporting people to live full and active lives.

Staff were committed to the provider’s vision and values and gave examples of how they implemented them in their everyday work. Staff consistently reported that they enjoyed working at the home and valued the support they received from managers. They told us that effective teamwork enabled them to deliver good standards of care.

The registered manager was visible within the service and regularly spent time on the units to observe staff practice, ensuring that care reflected the provider’s values. Staff told us the registered manager promoted an open and transparent culture, and they felt confident raising concerns. They demonstrated awareness of what a closed culture looked like and stated they were assured that management would act on any poor practice reported.People and relatives told us staff were generally kind, compassionate and respectful in their approach.

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 spoke passionately about her vision for the home. She described her aim to create an environment where every person feels safe, valued and truly at home, supported by a team who are empowered, motivated and proud of the care they provide. She aspired for the home to be recognised for delivering outstanding, person‑centred care, where dignity, choice and independence inform all decisions, and where families feel reassured that their loved ones receive the highest standards of care.

The registered manager was committed to building a warm and inclusive culture rooted in kindness, compassion, respect and accountability. She told us she wanted staff to feel supported, celebrated and encouraged to grow within their roles.

The registered manager described having a strong support network, including regular oversight and guidance from the area manager, the regional clinical lead and managers within the provider group. She received routine supervisions and appraisals from the area manager and participated in monthly manager review meetings, which provided opportunities for support, reflection and sharing best practice with the sister home.The registered manager had completed supervisions with staff. These showed staff demonstrated the skills, knowledge and competencies required for their roles and had opportunities to identify any additional support or development needs.

People and relatives knew who the registered manager was. Staff, people and relatives all told us the manager was approachable and operated an open‑door policy. They said she was accessible, responsive and willing to address any concerns raised.

People and relatives spoke positively about the management team, describing them as caring and approachable. Staff told us they felt supported and valued by the leadership team and were clear about their roles and responsibilities. A recent staff survey had many positive comments of support from the manager.

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

Staff were positive about the leadership within the home. One staff member told us the registered manager was “the best manager the home has had”. Leaders were visible and proactive during the inspection, and the manager told us she felt well supported by the provider.

There was a whistleblowing policy in place. Staff understood what whistleblowing meant, were aware of the provider’s internal processes and contact numbers and felt confident to raise concerns at any time. This included staff whose first language was not English, who demonstrated a clear understanding of how to speak up. Staff told us they felt assured that any concerns reported to the registered manager would be acted upon. People and relatives also told us they could raise concerns with the manager if needed.

The provider had systems in place for managing compliments and complaints. Although there had been no recent formal complaints, the registered manager was able to describe the actions she would take and demonstrated a strong understanding of investigation and response processes. She told us she aimed to resolve issues early by working collaboratively with staff and families before concerns escalated.

Both positive and negative feedback were shared with the staff team to promote learning and improvement. The registered manager and provider actively encouraged feedback through meetings, surveys, informal discussions, and the complaints and compliments processes. Information on how to raise concerns, including whistleblowing and complaints policies, was accessible within the home, supporting an open culture where people and staff felt able to speak up.

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 had completed equality and diversity training, and the provider had systems in place to assess staff competence following this learning, including competency assessments to review how staff applied their knowledge in practice.

Staff described an inclusive culture where diversity was valued, and discrimination was not tolerated. They told us the provider listened to their individual needs and implemented reasonable adjustments to help them carry out their roles effectively. Examples included flexible working arrangements and phased returns to work following periods of ill health.

We saw relevant risk assessments in place for staff with dyslexic traits, pregnant staff and transgender staff, and the service promoted LGBTQ+ inclusion. Staff had been recruited from diverse backgrounds that were reflective of the local community.

The service also celebrated religious and cultural events such as Eid, Diwali, Easter and Christmas, with staff and people sharing food, traditions and experiences. This supported an environment where cultural diversity was recognised and appreciated.

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, or share this securely with others when appropriate.

The registered manager and senior team carried out a range of audits and checks to monitor risk, quality and performance. Some checks focussed on compliance with legislative requirements, such as medicines management, infection prevention and control, and environmental safety. Other audits monitored outcomes for people, including accidents and incidents, activity engagement and staffing levels.

The provider also undertook regular quality assurance visits to monitor standards of care, safety and governance. Where shortfalls had been identified, we saw evidence that some actions had been taken to address these.

However, during this inspection we identified several areas that had been missed through the existing audit processes. These included potential environmental safety risks relating to cleanliness and condition of the premises, gaps in care plans and risk assessments, insufficient guidance for staff on health conditions and behavioural triggers, inconsistencies in pre‑assessments, and shortfalls linked to IDDSI, MCA and DoLS documentation.

The management team responded promptly to our findings. Immediate actions were taken to address some of the concerns during the inspection, and other issues were added to the provider’s improvement plan with clear timelines for completion. The registered manager assured us these would be incorporated into strengthened audit processes overseen by the area manager and regional clinical lead to ensure improvements were embedded and sustained.

The registered manager produced monthly data on key indicators, such as falls. Analysis included identifying trends around timing, location, footwear, walking aids and sensor mat responses. This allowed early interventions to be put in place, and the data showed falls had reduced following implementation of the fall’s toolkit and targeted actions.

There was an effective system for reporting maintenance issues, and records showed repairs were completed promptly by the maintenance person. Medicines audits were completed by a designated staff member and reviewed by the registered manager and regional clinical lead. Where medication errors occurred, these were followed up appropriately.

We found safe recruitment practices were in place, and the provider completed robust pre‑employment checks. Systems were also in place to assess staff competency and the effectiveness of training, ensuring staff understood and applied their learning in practice.

Safeguarding processes were effective. Staff understood how to recognise and report concerns, and where safeguarding issues had arisen, the correct procedures had been followed, with referrals made to the appropriate agencies.

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 worked proactively with a range of external organisations to support people, strengthen community links and improve outcomes. Staff told us they were able to make referrals to health and social care professionals through the management and nursing teams, and relatives confirmed that relevant professionals were actively involved in people’s care.

Feedback from health and social care professionals contacted during the assessment process was positive. Professionals described effective working relationships with the service and a shared commitment to improving people’s health, wellbeing and quality of life.

We saw examples of timely action following professional recommendations, including the provision of suitable equipment to enhance people’s mobility and comfort. For example, moulded chairs had been provided so people could spend time in communal areas rather than remaining in bed, supporting social engagement and wellbeing.

The provider worked in partnership with people, relatives and professionals to promote coordinated care. Information was shared appropriately with relatives when health‑related decisions were required. Staff told us they had access to specialist advice through established partnerships with healthcare services.

Staff also regularly engaged with community groups to ensure people’s broader social and emotional needs were met. Local nurseries and schools visited the home, and the provider invited the community to take part in events, celebrations and activities, helping people maintain meaningful connections outside the 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. They actively contributed to safe, effective practice and research.

The management team demonstrated a clear understanding of the improvements required in both care planning and the environment. They provided assurance these areas would be addressed promptly and showed strong commitment to implementing and sustaining meaningful, long‑term improvements.

Staff were supported to develop their skills, and several staff members told us they had progressed into more senior roles, which they viewed positively. The provider had processes in place to regularly review staff training needs and career aspirations, ensuring staff had opportunities for development.

People and their families were encouraged to provide feedback through reviews and relatives’ meetings. The provider operated a “You Said, We Did” approach, and we saw evidence that actions identified through feedback had been implemented.

The provider promoted a positive learning culture across the organisation. Staff described a ‘no blame’ approach, which encouraged them to be open about mistakes so that learning could be shared. Learning from accidents and incidents, including those occurring within other homes in the provider group, was disseminated to staff through established communication processes from the executive team.

Staff reward and recognition schemes were in place, including employee of the month, long‑service awards, vouchers and provider‑funded Blue Light Cards, which supported staff morale and motivation.

Following this inspection, the regional clinical lead introduced additional training and support on IDDSI, MCA and DoLS, as well as measures to enhance the lunchtime experience for people. These actions were implemented immediately and demonstrated the provider’s commitment to continuous learning and improvement.