Winterfell Care Home

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.

The provider’s policies and procedures underpinned their vision and values for the service. Staff understood their responsibility to provide care to people, in line with these values. We reviewed audits and reviews of care to further strengthen their values.

The management told us of improvement plans for the service, and that they had the full support of the directors to implement the changes and improvements in order to improve the environment at Winterfell Care Home.

Staff and leaders demonstrated a positive, listening culture that promoted trust and understanding between them and people using the service. There was a positive atmosphere and culture in the care home which focused on effective care and support for people. Staff spoke highly of the registered manager, their supportive leadership, clear communication, and genuine commitment to both staff well-being and resident care. Staff told us they felt supported by management, and residents told us management were approachable.

Minutes from staff meetings showed a clear, structured approach, with opportunities for staff to comment and have meaningful input.

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.

Leaders were knowledgeable about issues and priorities for the services and accessed appropriate support and development in their role.

Staff told us they felt well supported by the management. Comments included, “they are always there if we need them”. We observed the office door was open, meaning that staff, people who use the service, and people who visit the service had easy access to speak with management.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. When concerns are raised, leaders investigate sensitively and confidentially, and lessons were shared and acted on.

Staff were empowered to share their views in the service in both team and one to one supervision meetings.

There was a Whistleblowing policy in place which staff understood. We reviewed supervision notes where staff confirmed they understood the Whistleblowing policy.

The manager told us they operated an open door system and staff could approach them at any time. A staff member told us they felt they were listened to and their views about the service.

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. Leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity, and inclusion. There were relevant policies in place, such as equality and diversity.

Leaders ensured there were effective and proactive ways to engage with and involve staff, with a focus on hearing the voices through the means of supervision and staff meetings.

Staff told us they felt empowered and were confident that their concerns and ideas resulted in positive change to shape services and create an inclusive organisation.

Staff were involved and engaged in running the service, sharing their views and being listened to.

We did not find any incidents where staff reported that they felt bullied or expressed concerns about the workplace but were assured by staff that they would raise concerns if they did.

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 voice of people who use services were represented in the governance of the service by carrying out residents' meetings and during time spent with people who used the service and visitors.

We reviewed audits, action plans, spot checks which demonstrated that there was a clear governance process in place to evidence good quality assurance and management oversight.

Records were completed, and provided to us for meetings carried out, including staff supervision, staff and resident meetings and ward rounds.

The provider shared required information of incidents and accidents with relevant bodies, such as the local authority, CQC and the GP. We saw evidence of thorough lessons learnt and actions taken by the provider on risks when they had arisen. The provider told us of the hard work that they had completed in order to get the process in place, as it was an area noted as lacking depth in their last inspection by CQC.

Many of the shortfalls we identified during our assessment had been independently picked up by the management team at Winterfell Care Home. Where we had identified areas for improvement and shortfalls which had not been identified, the management team and provider took immediate action and provided evidence of having done so.

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 provider showed us evidence of ward rounds with the GP which they found to be a useful tool to have. They told us they felt they had a good relationship with the GP and could call them in between the ward rounds if the need arose.

The management told us they had good relationships with other professionals involved in people’s care. This included the Local Authority, mental health services, community nurses and dementia outreach.

We received feedback from professionals who visited Winterfell Care Home who told us that they had positive experiences and that staff knew the people who lived there well. External professionals told us staff worked with them to meet people’s needs in a joined-up way.

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 and effective practice.

There were systems for learning. These included regular staff meetings and supervisions. The registered manager discussed learning from accidents and incidents with staff. Quality assurance and lessons learnt evidenced change and continuous improvements when changes were identified.

There was a culture of openness and curiosity, with staff encouraged to share ideas and explore new approaches to enhance person-centred care.

The provider kept a training record. Although some staff required a refresher, the provider acknowledged this and action was being taken. The provider was committed to driving improvement in the service and shared a positive experience of having used both face to face and online training to equip staff with skills, knowledge and abilities to meet the wide range of needs people had at Winterfell Care Home.

Themes from any incident had been analysed by the management team to look for themes and trends. Lessons learned showed where the service could improve and that action had been taken to minimise future risk and improve the service both for people using the service, and staff.