Harrier Grange

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 good. At this assessment the rating has remained 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 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 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.

People and their relatives spoke of a friendly and caring service. Staff told us they felt supported, that communication was good and that there was “teamwork.” We saw minutes of staff meetings that showed staff were kept informed of the direction and goals of the service. We saw that the providers values were on display throughout the service.

Regular staff surveys were carried out. We viewed the latest survey results and the associated action plan, which showed staff feedback was listened to and acted on.

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 and the deputy manager were spoken of highly by people, their relatives and staff. People and their relatives spoke of the management team by name. One person said, “They’re great, they’re very engaging.” People’s relatives referred to an “open door policy” and told us the registered and deputy managers were both easy to approach. Staff told us the management team were “visible” and “always walking round the building.” Additionally, staff told us both the registered manager and deputy manager had a hands-on approach and were readily available to offer support and advice. One staff member said, “They [management team] know about any issues within the service and if you have your own problems you can go to them and tell them as well.”

One staff member said, “I think they’re very thorough. They listen to you. If I need anything I normally go to [deputy manager]. I like the afternoon meetings we have every day. [Registered manager] will just say it how it is, it’s honest and I think it’s good to be upfront about everything.”

The registered manager spoke highly of the entire team at the service. They told us they had developed “a stable, consistent, and highly committed team, whose ongoing dedication and support, continue to be the backbone of the service.”

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

Staff understood the whistle‑blowing policy, which was displayed in staff areas. The service had “speak up champions” who worked day and night shifts which meant all staff had access to them. Minutes of staff meetings encouraged staff to raise concerns with a champion if they did not feel able to raise it with a manager. Staff were aware of who they could speak to and told us they felt confident to do so. One staff member said, “You’re not restricted on what to say or how to escalate anything. You can say anything, you have to raise it.”

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 at the service, and the registered manager told us they supported staff to celebrate their cultures and take part in religious festivals. They told us, “Most of our staff are from overseas. I try to work with the staff to make them understand their role and improve their knowledge. They are very kind, friendly and compassionate. It's a big change for the staff here.”

Staff told us they felt included and valued. One staff member said, “I think there are lots of multinational staff here. For me I don’t think there’s any groups that I don’t feel part of.”

The registered manager had a clear understanding of their legal responsibilities. Statutory notifications, including safeguarding alerts, were submitted to the Care Quality Commission (CQC) in a timely and appropriate manner.

Daily observations were used to maintain consistency of care, alongside monthly audits which covered key areas such as care plans, medicines management, infection prevention, and health and safety. There was additional oversight from the provider’s senior leaders with regular focussed on-site visits.

However, governance systems were not always robust. Inconsistencies were seen across some of the records we looked at, which had not been identified through the provider’s audit systems. Although we saw no impact to people, and although the management team were prompt in putting corrective actions in place, the shortfalls in records did indicate that improvements in monitoring and oversight was required. There was a service improvement plan in place which we reviewed, and areas we noted during the inspection were added to this if they had not already been acted on or identified.

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 was well known in the local community. The registered manager told us about working with a local school and nursery, which included children writing to people, and attending joint activities. There was a local community church service weekly, and the local army wives choir visited to perform.

There were links with local health professionals and records showed people were reviewed for additional support as required. The registered manager told us they believed it was important to work as a bigger team with other health professionals in order toget the right support to meet people’s needs.

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 acted promptly and transparently to address issues identified during the inspection and they were open to our feedback during and after the inspection. They used feedback from people using the service, relatives, staff, and professionals to drive improvements and promoted a culture of learning to reduce the risk of recurrence. For example, we were told about specific training being rolled out to supplement other training in order to develop staff skills and staff told us how learning from incidents had been shared with the whole team in a supportive, but informative way.

Newsletters were sent to people and relatives which showed how the service was adapting and changing throughout the year, aligned with the changing seasons.