The Coach 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 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.

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. Staff were committed to providing support to people that improved their quality of life. One member of staff said, “We want people to enjoy being here and for this to feel like home, to be comfortable and supported, whilst maintaining as much independence as possible.” There was a person-centred culture at the service that was inclusive of families to ensure people’s needs were being met in a way they wished to be supported. A relative told us, “I get updates all the time, it is much more stable here now and I know what is happening. Staff here are smashing, everyone is nice.”

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. Since the last inspection a previous manager had returned to the service as the registered manager. We received positive feedback from staff, people and relatives about the return of the manager. One relative said, “I am glad [manager name] is back. The manager is approachable, and I know they will sort out any issues.” A member of staff said, “Since the manager has returned staff are more settled and relationships have improved. I feel much more supported.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Relatives told us they were confident to speak up and felt any issues they raised with the registered manager would be addressed. The registered manager empowered staff to raise concerns and staff told us they felt confident to speak up. One member of staff said, “Communication has improved, and the registered manager is proactive.”

The registered manager understood their responsibilities under duty of candour to be open and honest. When concerns were raised these were investigated sensitively and lessons shared and acted on. A relative told us, “I feel listened to and can discuss any concerns.”

There were ‘whistle-blowing’ procedures in place for staff to follow and staff had the opportunity to raise any concerns confidentially.

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 access to equality training to help them understand diversity, protected characteristics, bullying and harassment. Staff told us they felt they were treated fairly at the service, listened to and worked well together as a team.

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. The registered manager was able to access the provider’s systems and had a service improvement plan in place to give them oversight of the service and was able to monitor such things as staff training and supervision, environment improvements and maintenance and general governance audits. We found some audits still needed to have the actions recorded, with timeframes for completion. The registered manager assured us they would record actions taken following audits with timeframes for completion.

The registered manager completed statutory notification’s when required and notified partners following safeguarding concerns. The registered manager worked closely with the local authority to investigate safeguarding concerns to ensure people remained safe.

There were clear systems in place for workforce planning, such as recruitment and development of the workforce with additional staff roles identified and implemented, such as the clinical lead role.

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 had built good relationships with other health professionals such as the tissue viability team, palliative care and hospice team, speech and language therapists and GP surgery. Staff worked closely with these health professionals to provide person centred care. One health professional said, “The staff here are very good, we have good communication and discuss everything.”

Staff supported people to access the local community with trips out or to visit relatives. The activity co-ordinator also arranged events and entertainers who visited the service, which people enjoyed.

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. The registered manager shared learning at the service from accident, incidents, complaints and safeguarding concerns to improve outcomes for people. Staff were encouraged to develop their skills and keep up to date with training. There was now a clinical lead in place to help support nurses with the delivery of nursing care. The deputy manager informed us they were developing their skills by completing a management course so that they could further support the registered manager.

Staff were encouraged to share their feedback during meetings and supervision to help with the development of the service. People’s care was frequently reviewed with discussions with relatives and their input and ideas sought for care delivery.