Archived: The Leys

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 68 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People experienced a positive culture in their daily support. People were encouraged and supported to be involved in their local communities, keeping in touch with relatives, and their independence was promoted. Feedback from people and their relatives about the service's culture was positive. A person said, “We get to go out everywhere, I go to day care in the week. I get to go see [My relative]. I get to go on holiday and [staff member] takes me shopping. For my birthday, me and [another person] went to Euro Disney.”

The service had capable, compassionate and inclusive leaders. We received positive feedback about the deputy managers and operations manager. For example, A relative said, “I have a brilliant relationship with the [Operations Manager]. I have such respect for them and confidence in them. When [Relative’s] (relative) died during Covid and restrictions were in place, [Operations Manager] was [Relative’s] and my rock. [Operations Manager] keeps me up to date with what’s happening especially with the takeover going on. If I were to mention anything it would be taken seriously, I’m sure.”

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard. People, relatives and staff did not raise any concerns about being able to raise concerns. A person said, “If the staff where not being nice, I would tell [Operations Manager and Deputy Managers].”

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 did not raise concerns related to equality, diversity and inclusion.

At the time of our inspection, there had not been a registered manager in post for a prolonged period. This service is legally required to have a manager registered with CQC to oversee and be accountable for the day-to-day running of the service. The Operations manager told us the provider had been trying to recruit for this position but had not yet been unable to do so. They told us they planned to apply to be the registered manager themselves as an interim arrangement. CQC will continue to monitor this.

As highlighted in our report, there were some aspects of the service needed improvement, such as care planning for people, and the environment. Although we did not identify that people had been impacted by these findings, the provider’s governance systems had not addressed these areas prior to our inspection. In response to these findings, the provider told us they would take action and improve. We will check for sustained improvement at our next inspection.
 

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. We saw evidence of external health professionals being involved in people’s care such as GPs, dentists and opticians. Relatives told us they were kept up to date and informed of any changes to people’s needs.

We found improvement such as refurbishment was needed to the environment and this was known to the provider. At the time of our inspection, we were informed the service was going through a sale and transfer to a new provider. Staff we spoke with were hopeful that the new provider would invest in the service and improve areas that needed refurbishment which would improve people’s living environment. A relative said, “The home is being taken over by a local experienced company. The staff are very enthusiastic. They’re hoping some money will come in to upgrade the home as it’s looking a bit dated.”

The operations manager maintained regular oversight of the service through regular visits and audits, including health and safety, infection prevention and control and learnings from accidents and incidents.