Goatacre Manor 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 remained Good.

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.

Leaders had a clear vision of the service. This was to put people first, ensure they were empowered, their rights were respected, and a good quality of life was enabled. They said in addition to this, an open culture where staff were supported and enabled to share their views, was promoted.

Staff confirmed the service had an open culture, and everyone wanted the best care for people. They said leaders were visible, approachable and always willing to help. This included often working alongside staff, which enhanced morale and openness. One staff member confirmed this, and said, “Happy carers, happy residents. It's friendly here.” We overheard another staff member talk to a person on the telephone about a possible referral to the home. The staff member engaged positively and demonstrated the service was person-centred and responsive to individual preferences.

Leaders and staff told us they aimed to ensure people treated the service as their home. This included enabling people to follow their own routines and do what they wanted, whilst surrounded by their personal possessions. One relative confirmed this. They told us, “They make it like home, just with added safety.”

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 told us they promoted open discussion, and believed they had a calm, inclusive approach. They said they aimed to give staff autonomy, to be open and honest and develop through ongoing learning. They said this was important for them too, so always gave staff a feedback form after their supervision meeting. This enabled them to use staff’s feedback to improve as a leader.

Leaders told us being responsive to staff’s needs was important to them. They said reasonable adjustments were made as required, to enable staff to work to the best of their ability. Leaders told us this could include a change in shift pattern, lighter duties or a reduction in working hours, dependent on need.

Staff were complimentary about leaders, and said they were approachable, listened and were supportive. One staff member told us, “[The manager] is amazing. They always have time for you, and have a brilliant way of being supportive whilst also helping any learning. They are the best manager I’ve ever had.”

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

Staff told us there was an open culture where they felt confident to speak up. This included regular discussions with leaders and staff meetings. Staff told us if they were unable to attend the meeting, they were provided with the minutes. This enabled them to keep up to date with information and share their views with leaders. One staff member told us, “We are encouraged to speak up in the meetings, and things change. I do feel supported here.” Another staff member said, “When I first came here to work, I was sceptical because I was told everyone is part of the team, but here it really is true.”

Staff were confident they would be listened to, and their concerns would be taken seriously, and addressed. Leaders confirmed this. They said it was important to have an open culture, where any concern would be raised immediately.

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 told us they had a very diverse team which they valued. They said the team brought a wealth of experience, with many different skills and expertise. Leaders told us different cultures were celebrated, which promoted learning and minimised discrimination. There was a strong focus on being kind and treating people, and each other, with respect.

Staff told us they felt included and considered themselves part of the team. One staff member said, “We have a nice team here, good teamwork. Me and colleague [from the same country overseas] dressed up last year. It is a multi-cultural team, and the residents like to see our traditional dress.”

Staff had completed training in equality, diversity and inclusion.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Leaders were well supported, and able to regularly discuss the running of the home with senior managers. They said they worked well together and complemented each other’s roles.

Leaders had a clear presence in the home, and spoke to people, relatives and staff regularly throughout the day. They worked alongside staff and observed practice to identify any areas which could be improved upon. Leaders told us these were discussed with staff openly, and learning was encouraged.

Records demonstrated there were a range of audits to ensure compliance. This included areas such as health and safety, infection prevention and control and the environment. There was an electronic system which informed leaders if staff needed refresher training in a particular topic. Any actions identified from the audits, formed part of the home’s improvement plan.

However, audits such as the medicine and care planning audits were not adequately detailed. This was because shortfalls we found during the inspection, had not been identified. Leaders had discussed the outcome of clinical audits with staff, but records did not demonstrate patterns and trends had been analysed. This did not evidence the information was being used to further develop practice. Leaders told us they would address this moving forward.

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 worked well with other health and social care professionals to meet people’s needs. This included the GP, podiatrist, pharmacist and specialist nurses. Referrals to speech and language therapists and dieticians were made as required.

Leaders worked with training organisations and local services to ensure staff had the knowledge and skills to undertake their role. This included the local hospice, for quality end-of-life care and a nutrition nurse for the management of a percutaneous endoscopic gastrostomy (PEG). A PEG is a surgical procedure which allows the person to receive their nutrition, via a feeding tube.

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.

Leaders had a positive approach to learning and developing the service. They said, “There are always things we can do differently. We’re always looking at what we can improve, what’s happened, is it systems, dynamics, what is it?” Another leader told us “We want to do the best we can for people, so we welcome feedback. We always use it to improve, that’s what it’s all about.” This ethos was adopted by staff, with training and reflective practice an important part of their role.

Developments had been made in response to people’s feedback and that of staff. This included more outside seating areas and rearranging the dining tables to make the room a more sociable space.

Leaders were receptive to our feedback and immediately took action to address shortfalls. This included arranging care reviews, and a full review of each person’s care plan and associated records.