Grace Care Centre

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 changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the culture they created drove and improved high-quality, person-centred care.

This service scored 93 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities. The registered manager had clear expectations in how they wanted the service to be managed. This included supporting people, to remove any barriers from their care and to enhance their wellbeing. They worked with the provider’s vision and values. The service was referred to as a community by the registered manager, where staff worked with people to create a truly person-centred environment. Where people could not take part in external activities, these were brought to the service for people to enjoy. A local donkey, reptile and penguin organisation had visited the service separately for people to enjoy. This had created great enjoyment for people, new experiences and positive interactions. One person described the donkey experience as “Wonderful”. It had brought back many childhood memories. Relatives and staff noticed positive emotional responses from people.

Professionals gave positive feedback about the culture of the service. A professional told us. “The atmosphere in the service was warm, with a welcoming approach. The culture enabled staff to provide people with the best outcomes.”

Staff were encouraged to get to know other staff roles. An example included the handy person, who had basic care experience and training. They spent the day working as a care assistant, to experience the role. The registered manager told us, “They demonstrated exceptional flexibility, commitment to the service, and a strong team ethos.” The staff member reflected how demanding the role of the carer was and how hard the staff worked. Staff described a culture of being encouraged to provide the best care to people. A staff member told us, “I feel we all share the same vision as staff, in wanting to provide the best care to people. We are encouraged to learn each other’s roles and help each other.”

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 deputy were, dedicated, enthusiastic and passionate about their role. The registered manager had been in post for 2 years. They told us positive changes had been made to the service, with new staff recruited. They were committed to ensuring people experienced high levels of person-centred care and led by example. They had established a good relationship with visiting professionals. A professional told us, “I feel our team have a good relationship with the care home, who are easy to contact. I feel we have a strong working relationship, with no concerns or issues to report.”

People and relatives spoke positively about the leadership of the service, “A person told us, “I do know the managers very well. If I do have a big problem I go through my friend. She goes to see the manager, and she makes sure I hear what they say. “A relative told us, “I know the manager. If I had an issue and needed to speak to them, I could.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. We received some mixed feedback from the staff about the support they received when they have spoken up. Examples included, A staff member told us, “I feel listened to, when I have had to challenge things and speak up”. Another staff told us, “No, I do not feel listened to.” We discussed the mixed feedback with the operations manager. They told us listening days had been held with them, the staff and representatives from the human resources department. This gave the opportunity for the staff to speak up and seek support. The registered manager, deputy and the operations manager encouraged staff to be open, transparent and to speak to them. The operations manager regularly visited the service and carried out ‘stop and drop’ sessions. These were sessions which staff could attend to discuss any suggestions, share feedback or discuss any concerns.

The service had a ‘you said, we did’ system where people could share ideas about things they wanted or to be improved. An example was 1 person had said the meat at mealtimes was sometimes hard to chew. As an outcome, the service purchased a new meat slicer, and meat was sourced from another provider. The outcome was shared with people, who reported in ‘resident meetings’ that this had improved and meat was now tender.

The provider strongly valued diversity in their workforce. They had an inclusive and fair culture which had improved equality and equity for people who worked for them. The service had a diverse team of staff, where equal opportunities applied without fear of discrimination. Staff were supported from the outset of the recruitment process. Some staff had been employed with protected characteristics. The registered manager had supported applicants who were nervous before the initial interview, by meeting with them prior, to help reassure them. After the interview process, an applicant had written to the registered manager, to thank them for giving them the opportunity. The registered manager supported staff through access to work. Some staff’s working hours were adjusted to help meet their needs, with training sessions adapted to support them. A member of staff told us, “The registered manager had really supported me through a difficult time. They looked at my hours and gave me flexibility”. Staff were supported to work flexible hours, when possible, to help them celebrate their own cultural events. The service encouraged all staff and people to celebrate these events and to learn about different faiths. Support was given to staff going through the menopause and pregnancy. This included support sessions with managing the menopause. Adapted uniforms were available for staff going through pregnancy and the menopause. They were designed to be lightweight, breathable and to reduce discomfort. One staff member told us, “The provider was really supportive, and the uniforms had made a difference to them and others.”

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver high-quality, sustainable care, treatment and support. They always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider and the management team at the service had a comprehensive governance system, which had been embedded. There was a culture of transparency, learning and improvement at all levels. Audits were undertaken at both service and provider level to ensure a high level of quality care was provided to people. Effective audits were undertaken of medicine records, people’s care records, health and safety and staff records. These audits contained high levels of detail, identified trends, with an analysis completed. They were used to identify actions which were then added to the provider’s service improvement plan. The service improvement plan contained actions identified and completion dates. The information from this was used effectively to improve service delivery. For example, an audit found an increase in some people falling. Initiatives undertaken to reduce falls included the use of equipment to monitor falls, call bell audits, an analysis of falls to identify trends for each person, review meetings held, discussion with the GP, a review of medicines and more frequent checks being carried out. This had helped to reduce the number of falls for people, which had exceeded all expectations. The collaborative approach encouraged staff to contribute ideas and observations that may not have been previously identified. For example,1 person had experienced on average 5 falls per month, but this had reduced to zero. Overall, the service had significantly reduced the number of falls through using this proactive initiative. In comparison in January 2025 the service averaged 20 falls per month, but this had reduced to 8 falls on average per month by February 2026. This practice was shared with registered managers, within the providers other care homes.

The registered manager completed daily walkarounds of the building. This was also carried out by a provider’s representative when they visited weekly. This was to ensure high standards were maintained of the building and care delivery. They spoke with staff and people to check they were happy with the quality of care provided. The checks included observations, checks of staffing levels, cleanliness and the quality-of-care given to people. The provider’s regional quality assurance team carried out robust audits of the service and continually monitored the service. It was clear that people enjoyed the visits from the operations manager, they were well respected by people and the staff and had a good rapport.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement. The registered manager had established strong links with the local community. The service was part of a programme called re engage, where people in the community who were lonely could visit the service to take part in activities and events, such as the knit and natter groups. They had formed strong friendships with people and the community. Some people who lived in the community were able to seek support, with living with dementia and were signposted to the appropriate organisations. People living at the service were also able to share their own experiences with living with dementia. The engagement programme supported positive mental wellbeing outcomes and socialisation for people and the community.

The service had made links with local schools who visited the service to perform at events including singing and nativity plays. Most recently children at a school had taken part in the services’ paint a penguin competition, which was judged by people who lived at the service. The service was a keen supporter of charity. Due to some people living in the service with Parkinson’s disease, this was a charity close to people and staff. Some staff and people had baked cakes and attended a charity event at the local school. The cake sale raised money for this charity. A local school of performing arts visited weekly to perform shows for people. Other community links involved with the service included the local scout and brownies group. The service was a donation hub for the local food bank. Where items could be collected and distributed efficiently. People, volunteers and the staff were keen to support the charity.

The provider had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always 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 provider had invested in a non-intrusive monitoring system, which was turned on at night. The system supported staff to monitor, improve and promote person centred care, along with privacy and enhanced their independence. The system was only set up in people’s rooms, for those people who wished to have this. It was motion detected to provide additional visual confirmation of events triggered by alerts. This meant that people did not need to be checked throughout the night meaning they had undisturbed sleep. Sounds were detected that were associated with falls or distress, with alerts sent to the staff. The service had analysed the results, which showed good outcomes for people. This included a reduction in falls, incidents, a faster staff response to potential falls and distress, reduced wait time for people being on the floor and improved night-time monitoring without intrusive checks.

Staff described the provider and registered manager as having a strong focus on providing good outcomes for people. They felt the service continuously looked to improve, the quality of life for people. A staff member told us, “From day one I valued the approach here. The registered manager looks to be one step ahead, looking at ideas to improve people’s life’s.” Another staff told us, “Yes, I feel the provider is driven and creative. They want us to do well, and I feel we always do are best.”

The provider had a strong emphasis on championing people’s care. A number of staff had special key roles within the service. This included a safeguarding lead, dementia lead and a specialist nurse who provided advice to staff and people. The registered manager had nominated staff for various awards and were keen to celebrate the staff’s achievements. This included nominating a staff member for a dementia care award, due to their hard work and commitment. The provider also held its own yearly awards to celebrate achievements.